1 Month in which these health encounters occurred
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January February March April May June July August September October November December
2022 2023
1 Month and year in which these health encounters occurred
Enter the month and calendar year that the services were provided. (Do not enter the date you submitted the report. Do not enter the fiscal year or the school year.)
2 Are you reporting for a public school district, school union, charter school, collaborative, or nonpublic school?
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Public school district, school union, charter school, or collaborative
Nonpublic school
3 School district
Select your school district, school union, charter school or collaborative. If your school is not in the list, scroll to the bottom of the list, select "Other", and enter the name of your school in the box that will appear below.
Submit a single report for the entire school district rather than a separate report for each school. School Unions: Submit one report that includes all the schools in the union and any related regional schools.
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Alma del Mar Charter School (District) Amesbury Amherst-Pelham (Regional + School Union) Andover Arlington Ashburnham-Westminster Assabet Valley Collaborative Attleboro Barnstable Belchertown Bellingham Belmont Berkshire Arts and Technology Charter Public (District) Beverly Billerica Blackstone-Millville Boston Boston Collegiate Charter (District) Braintree Bridgewater-Raynham Brockton Brookline Burlington Cambridge Canton Cape Cod Collaborative CAPS Education Collaborative Carver Chelmsford Chelsea Chicopee Collaborative for Educational Services Concord-Carlisle Danvers Dedham Dennis-Yarmouth Dover-Sherborn (Regional + School Union) Dudley-Charlton Reg Duxbury East Longmeadow Easton Fairhaven Falmouth Fitchburg Foxborough Framingham Francis W. Parker Charter Essential (District) Freetown-Lakeville Frontier (Regional + School Union) Gardner Gateway Gloucester Greenfield Greenfield Commonwealth Virtual District Hampden-Wilbraham Hanover Harvard Hatfield Haverhill Holliston Holyoke Hudson Ipswich Leicester Leominster Lexington Ludlow Lunenburg Lynn Lynnfield Mansfield Marlborough Marshfield Masconomet Mashpee Medfield Medford Melrose Methuen Middleborough Millbury Millis Monson Nahant Narragansett Nashoba Nauset (Regional + School Union) Needham New Bedford Newburyport Newton North Andover North Attleborough North Brookfield North Middlesex Northampton Northbridge Norton Norwood Old Rochester (Regional + School Union) Pathfinder Regional Vocational Technical Peabody Pembroke Pioneer Valley Plymouth Quabbin Reading Salem Sharon Shrewsbury Sizer School: A North Central Charter Essential (District) Somerville South Hadley South Shore Educational Collaborative (SSEC) Springfield Stoneham Stoughton Swampscott Swansea Tantasqua (Regional + School Union) The Education Cooperative (TEC) Wachusett Walpole Waltham Watertown Wayland Wellesley West Springfield Westborough Weston Weymouth Wilmington Winchester Woburn Worcester Other
Enter a few letters to search the list.
Other public school (Specify)
4 Nonpublic school
If your school name is not in the list, scroll to the bottom of the list, select "Other", and enter the school name and address in the box that will appear.
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Andover School of Montessori, 400 South Main, Andover Bais Yaakov of Boston, 198 Strathmore Road, Brighton Cambridge Montessori School, 161 Garden Street, Cambridge Cape Cod Academy, Inc., 50 Osterville West Barnstable Road, Osterville Catholic Memorial School, 235 Baker Street, West Roxbury Diocese of Fall River (All Saints Catholic School 115 North Illinois Street New Bedford) Diocese of Fall River (Bishop Connolly High School 373 Elsbree Street Fall River) Diocese of Fall River (Bishop Feehan High School 70 Holcott Drive Attleboro) Diocese of Fall River (Bishop Stang High School 500 Slocum Road North Dartmouth) Diocese of Fall River (Espirito Santo Parochial School 143 Everett Street Fall River) Diocese of Fall River (Holy Name School 850 Pearce Street Fall River) Diocese of Fall River (Holy Trinity School 64 Lamphor Street Fall River) Diocese of Fall River (Our Lady of Lourdes School 52 First Street Taunton) Diocese of Fall River (St. Francis Xavier School 223 Main Street Acushnet) Diocese of Fall River (St. John Paul II High School Division 120 High School Road Hyannis) Diocese of Fall River (St. John Paul II Preparatory Division 33 Cross Street Hyannis) Diocese of Fall River (St. John the Evangelist School 13 Hodges Street Attleboro) Diocese of Fall River (St. Joseph's School 100 Spring Street Fairhaven) Diocese of Fall River (St. Mary Sacred Heart School 57 Richards Avenue North Attleboro) Diocese of Fall River (St. Mary's Catholic School 330 Pratt Street Mansfield) Diocese of Fall River (St. Michael School 209 Essex Street Fall River) Diocese of Fall River (St. Pius X School 321 Wood Road South Yarmouth) Diocese of Fall River (St. Stanislaus School 37 Rockland Street Fall River) Diocese of Fall River (St. Teresa of Calcutta School 180 Orchard Street New Bedford) Gann Academy-The New Jewish High School, 333 Forest Street, Waltham Gateway Access to Jewish Education, 333 Nahanton St, Newton Gateway (Jewish Community Day School, Watertown) Gateway (Solomon Schechter Day School, Newton) Holy Name Parish School, 535 W Roxbury Pkwy, West Roxbury Immaculate Conception School, 1 Washington Street, Newburyport Lawrence Catholic Academy, 101 Parker Street, Lawrence Lowell Catholic, 530 Stevens, Lowell Maimonides, 34 Philbrick Rd, Brookline Pope Francis Preparatory School, 134 Springfield Street, Chicopee Sacred Heart Elementary, 75 Commercial, Weymouth Saint Bridget School, 832 Worcester Rd, Framingham Saint Joan of Arc School, 587 Grattan Street, Chicopee Saint Michael School, 80 Maple Avenue, North Andover Shaloh House Day, 29 Chestnut Hill Avenue, Brighton St Anna School, 213 Lancaster St., Leominster St Bernard Elementary, 254 Summer Street, Fitchburg St Joseph Elementary, 90 Pickering, Needham St. Stanislaus School, 534 Front Street, Chicopee Striar Hebrew Academy, 100 Ames Street, Sharon The Learning Center for the Deaf School, 848 Central Street, Framingham The Rashi School, 8000 Great Meadow Road, Dedham Torah Academy Inc., 11 Williston Rd, Brookline Venerini Academy, 23 Edward, Worcester Other
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Other nonpublic school (Enter name and complete address)
5 Name of person completing report
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6 Email address
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Type of encounter Students Staff In-person Remote (Virtual, telehealth)
Enter the number of encounters for nursing services this month.
Note: The number of in-person encounters is used to calculate the return to class rate which is the number of students returning to class divided by the total number of encounters. Each student visit to the health office or nursing assessment/intervention occurring outside health office (i.e. classroom, playground, cafeteria, etc.) counts as a SINGLE encounter, regardless of the number of procedures done or medications administered during that visit. Mandated screenings DO NOT count as visits. Students' seen more than once during the school day would be counted as a new encounter for every new visit.
Number of in-person STUDENT encounters for nursing services this month
Number of in-person STAFF encounters for nursing services this month
Number of remote STUDENT encounters for nursing services this month
Number of remote STAFF encounters for nursing services this month
Emergency Mobile Crisis Unit dismissal
Referred to the counselor
Sent home to return later that day
View equation
1. Returned to class
2. Dismissed from school due to illness:
a. Non-emergency dismissal
b. 911 emergency dismissal
3. Dismissed from school due to injury:
a. Non-emergency dismissal
b. 911 emergency dismissal
4. Dismissed from school due to behavioral health:
a. Non-emergency dismissal
b. 911 emergency dismissal
c. Emergency Mobile Crisis Unit dismissal
5. Other disposition:
a. Stayed in health room
b. Referred to the counselor's office
c. Sent home to return later that day
d. Other
6. TOTAL (automatically calculated)*
*I n this form, all numbers shown in red font are automatically calculated and do not indicate an error.
View equation
The number of students returned to class cannot be greater than the total number of in-person student encounters. Please check your data.
Returned-to-class (RTC) rate (%)
View equation
Automatically calculated
Returned-to-class rate % Automatically calculated
Type of injury Students
Staff
Unintentional
Intentional
Intent Unknown`
Unintentional injury (Students)
Unintentional injury (Staff)
Intentional injury (Students)
Intentional injury (Staff)
Intent Unknown injury (Students)
Intent Unknown injury (Staff)
Type Students Staff Occurring during school-sponsored activities
Occurring during out-of-school activities
Occurring during school-sponsored activities
Occurring during school-sponsored activities
Occurring during out-of-school activities
Occurring during out-of-school activities
Number of emergency doses administered to staff and visitors this month:
Type of Emergency Medications Staff
Visitors
1. Epinephrine
2. Glucagon
3. Naloxone (Narcan)
12a scheduled analgesic prescriptions
12a prn anagesic prescriptions
12a scheduled antibiotic prescriptions
12a anticonvulsant prescriptions
12a prn anticonvulsant prescriptions
12a antihypertensive prescriptions
12a prn antihypertensive prescriptions
12a antihistamine prescriptions
12a prn antihistamine prescriptions
12a
12a
12a prn epinephrine (non-asthma related) prescriptions
12a prn glucagon prescriptions
12a
12a
12a naloxone (Narcan) prescriptions
12a psychotropic prescriptions
12a prn psychotropic prescriptions
12a
12a
12a View equation
View equation
12b scheduled analgesic prescription doses adminstered?
12b prn anagesic prescription doses administered?
12b scheduled antibiotic prescription doses administered?
12b anticonvulsant prescription doses administered?
12b prn anticonvulsant prescription doses administered?
12b antihypertensive prescription doses administered?
12b prn antihypertensive prescription doses administered?
12b antihistamine prescription doses kept administered?
12b prn antihistamine prescription doses administered?
12b asthma prescription doses administered?
12b prn asthma prescriptions doses administered?
12b prn epinephrine (non-asthma related) prescription doses administered?
12b prn glucagon prescription doses administered?
12b prn antihypertensive prescription doses administered?
12b insulin prescription doses administered?
12b naloxone (Narcan) prescription doses administered?
12b psychotropic prescription doses administered?
12b prn psychotropic prescription doses administered?
12b other prescription doses administered?
12b other prn prescription doses administered?
12b
12b prn otc doses administered?
12b Total prescription doses administered?
View equation
12b Total PRN prescription doses administered?
View equation
13 Parent Guardian (less than 15 minutes)
13 Parent Guardian (greater than 15 minutes)
13 School Staff (less than 15 minutes)
13 School Staff (greater than 15 minutes)
13 Community Agencies (less than 15 minutes)
13 Community Agencies (greater than 15 minutes)
13 Group Meetings (less than 15 minutes)
13 Group Meetings (greater than 15 minutes)
Type of Communication
Length of Time
# of Communications
Parent / Guardian
< 15 Minutes
≥ 15 Minutes
School Staff
< 15 Minutes
≥ 15 Minutes
Community Agencies
< 15 Minutes
≥ 15 Minutes
Group Meetings
(With 2 or more of the above participants)
< 15 Minutes
≥ 15 Minutes
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