MICHIGAN SCHOOL NURSE
FAQ
A summary of frequently asked questions
regarding school nursing in Michigan
Instructions for use:
The questions most frequently asked are organized into 8 topics for easy
navigation:
School Nurses in Michigan
Health Services Delivery
Laws
Delegation of Nursing Practice
Administration of Medication
Chronic Conditions
Communicable Disease and Infection Control
Additional School Health Concerns
Frequently Asked Questions
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SCHOOL NURSES IN MICHIGAN
Are school nurses required in Michigan?
Both the American Academy of Pediatrics and the National Association of School
Nurses recommend a full-time school nurse in every building. There is no statutory
requirement for Michigan schools to employ a nurse, but if the school DOES, it must
comply with this section of the Michigan Education Code, Act 451 of 1976 – 380-
1252, which states:
• The board of a school district may employ registered nurses necessary to
provide professional nursing services. The services shall be operated under
rules promulgated by the state board which shall establish the certification
requirements for registered nurses in the services.
• The state board may require reports and information from school districts
offering nursing services.
• This section does not apply to nursing services provided by a county or district
health department.
Federal laws require schools to provide related nursing services by guaranteeing
access to education and related services to assist children with disabilities that
benefit from special education per 34 CFR Part 300 Individuals with Disabilities Act
of 1997 (IDEA). Additionally, Section 504, Rehabilitation Act of 1973 protects the
rights of children with special health-care needs (CSHCN) by providing related
services, including health services, to those not eligible for special education.
What are the requirements for a Registered Nurse (RN) to work as a
school nurse in Michigan?
To be a school nurse in Michigan, you must be a registered nurse licensed by the
state of Michigan. Michigan school nurse practice is governed by the Michigan
School Code and the Michigan Public Health Code which is different from many
states that are governed by a state Nurse Practice Act.
The Michigan Board of Education requires that all school nurses be properly certified
by the state. This certification includes continuing education and work experience.
A School Nurse Certificate can be obtained in stages.
An RN with a Bachelor of Science degree qualifies for Interim School Nurse
Certification for working in a school during the first 2 years. They may apply for the
Standard School Nurse Certification after completing 2 years. This school nurse with
3 years of experience, qualifies for Professional School Nurse Certification.
A RN with an Associate’s Nursing degree (ADN) can only apply for the interim
School Nurse Certification, which is good for 2 years. They can reapply for and
qualify for another 2 years and must meet the requirement of at least 8 hours of
continuing education related to school nursing.
After 2 years of work as an Interim school nurse and 15 hours of additional learning,
the ADN RN will qualify for Standard School Nurse Certification, which is good for 3
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years. They can reapply and qualify for another 3 years before they are required to
qualify for the Professional School Nurse Certification.
The ultimate goal is for all school nurses to have a BSN or working toward their BSN
over a 10-year period.
The RN must be certified, according to the rules of Michigan Online Educator System
(MOECS), effective July, 2023, Public Act 110 of 2023 and Public Act 111 of 2023
was signed into law which expands reciprocity and supports experienced educators
in becoming certified or recertified in Michigan.
RN’s are currently not able to apply for themselves. The application must be done
by someone in the district who has access to MOECS.
The National Association of School Nurses (NASN) also recommends National School
Nurse Certification. Information on national school nurse certification is available at
the National Board of Certified School Nurses (NBCSN).
As a new school nurse in a district that has never had a school nurse,
where do I begin?
This situation can be overwhelming for both the school nurse and school
administration. Contact your Intermediate School District (ISD) or local health
department to see if there are other school nurses in your county. Other
connections include the Michigan Association of School Nurses and the National
Association of School Nurses.
• Make sure the MI State School Nurse Consultant has your work email address.
• Look for trainings from the MI State School Nurse Consultant:
o School Nurse Summer Institute (August)
o School Nurse Winter Institute (January)
• Attend a Foundations for Effective School Nurse Practice training when
available.
• Attend a Medical Emergency Response Team (MERT) training when available.
• Review the resources necessary to align your school nurse practice with the
Framework for the 21
st
Century School Nurse Practice.
• Begin with looking at the Back to School Toolkit (checklists) and +
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What resources are available for a new school nurse to use?
• Laws & Model Policies that Guide School Health Services Programs in Michigan
• Michigan Consideration Documents
• Prioritizing School Nurses Practice Activities
• Framework for 21st Century School Nurse Practice
• National Association of School Nurses (NASN) Professional Practice Documents
• NASN Back to School Toolkit
• MASN School Nurse 101 member /MASN nonmember
• Safe & Legal Support of Students’ Health Needs (MASN membership required)
• What Do School Nurses Actually Do? (Infographic)
• What Do School Nurses Actually Do? (Narrative)
• The Role of the School Nurse: A Vital Part of Today’s Health Care System
• NASN Bookstore:
o School Nursing a Comprehensive Text
o School Nurse Resource: Tenth Edition
o Legal Resources for School Health Services Programs
o School Nursing: Scope and Standards of Practice, 4th Edition
What educational and training modules are available for school
administrators?
Resources: (In Progress)
• 5 Ways a School Nurse Benefits the School
• School Administrator Training and Educational Resources (Project in Progress)
• Center for Disease Control (CDC): School Health Services
• CDC: School Nurses Help Keep Students Healthy
• What Do School Nurses Actually Do?
How many school nurses practice in Michigan?
MASN Support and Sustainability for Michigan School Nurses Infographic.
What is the ratio for school nurses to students?
There are many factors that must be taken into consideration when determining the
school nurse to student ratio. A standard ratio of the school nurse to student alone,
is not evidenced based. Other factors to take into consideration are:
• Student health needs, safety, and medical acuity.
• Community and school infrastructure.
• Social determinants of health.
• Understanding the complexities of the role of the school nurse.
• The environment and culture of the school/school district that influences
services delivered.
• Characteristics of nursing staff.
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The National Association of School Nurses (NASN) believes that school nursing
services must be determined at tiers sufficient to provide the range of health care
necessary to meet the needs of school populations. All students need access to A
School Nurse Every Day.
School Nurse Workload (Position Statement, 2020).
How do Michigan schools address health services delivery if nurses
are not required?
When school nurses are not available to provide health services to students, this
responsibility is assigned by the school principal to other staff, usually office staff or
other paraprofessionals. Some districts include health services delivery as a
responsibility of teachers. If a student requires a health-related service because of
an eligible health concern, the school will investigate the need for an Individualized
Education Plan (IEP) or a 504 Accommodation Plan to meet the child’s needs and
provide required nursing services.
What do school nurses actually do?
“School nursing, a specialized practice of nursing, protects and promotes student
health, facilitates optimal development, and advances academic success”. Adopted
by the NASN Board of Directors February 2017. School nurses are registered nurses
and licensed health care professionals who play a vital and challenging role in
schools. They have received a thorough education and rigorous training, and are
"real nurses” just like those employed by hospitals, doctor's offices, home health
agencies, etc. Although certification regulations vary by state, the National
Association of School Nurses recommends that school nurses have a bachelor's
degree and be a registered nurse. School nursing is a professional registered
nursing specialty. Michigan School Nurse certification rules define "school nurse" as
a registered nurse, however, school districts in Michigan are under no legal
requirement to hire RNs, so the person in the nurse's office might not actually be a
nurse. If that is the case, the unlicensed person should not use the title "nurse”.
The job of the school nurse has grown and expanded considerably over the years
and is based on the Framework of 21st Century School Nurse Practice. School
nurses fill the gap between healthcare and education, provide both acute and
chronic care, treat and assess behavioral health concerns, connect the student and
family to community resources, and manage students with chronic conditions such
as asthma, food allergies, diabetes, seizures and other chronic health conditions
which require special care during the school day. In any given day, the school nurse
may see as many as 50-100 or more students and must also have the professional
judgment and skills necessary to:
• Provide both population and individual care and actively communicate with
healthcare providers.
• Develop individualized healthcare plans and emergency plans for all children
with healthcare needs.
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• Provide preparedness planning and compliance utilizing best practice.
• Prepare plans for healthcare needs of the school community in the event of a
disaster or lock down situation.
• Assess lung sounds of students with asthma and provide appropriate
treatment if indicated.
• Communicate with parents/guardians, teachers, or physicians regarding the
effectiveness of medication for a student with any health condition (i.e.,
attention deficit/hyperactivity disorder, diabetes, asthma, sickle cell disease).
• Care for a child with a seizure.
• Perform a complex treatment for a child with special health care needs, such
as suctioning a tracheostomy or administering medication via a feeding tube
or intravenous port, urinary catheterization, and toileting for a disabled child.
• Provide training to school staff on appropriate treatment and procedure,
general education on disease management, and how to monitor and respond
to emergencies.
• Respond to a school related emergency, such as a playground accident, a
school bus accident or some other critical incident that affects the health, and
safety of students or staff.
• Facilitate screenings such as dental, vision and hearing.
• Facilitate medication administration (emergency and routine).
• Attend a parent/guardian conference or Individual Education Plan or 504
meeting if student health concerns are affecting learning.
• Provide supplemental classroom instruction and materials on various health
related topics.
• Provide one-on-one health counseling to individual students.
• Provide school health services both in-person and remotely.
• Serve as a resource for families in need of support through community or
social agencies or programs.
• Promote and provide diverse education addressing social, mental and health
needs.
• Play a vital role in planning and executing a safe return to in-person learning
when needed.
• Be confident and prepared to handle every health-related incident that may
occur.
• Lead the district in developing policies related to school health services and
safety concerns.
• Participate in multidisciplinary teams both in district and the community.
In addition to performing a broad range of health functions, the school nurse
communicates with parents/guardians, school staff, public health agencies and
healthcare offices regarding communicable disease outbreaks, and other health
concerns. The school nurse may also plan and implement school wide health
education campaigns or activities such as health fairs or special health observance
days. The school nurse may give presentations to parent/guardian or community
groups.
The school nurse is also responsible for organizing and maintaining the health-
related documents, such as immunization records and health information forms for
each student. It is vital that the school nurse know where parents/guardians or
other caregivers can be reached during the day in case of an emergency. The nurse
should also know the name of a child's pediatrician, which local hospital
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parents/guardians would prefer their child be taken to if they cannot be reached,
and, if school policy allows, whether a child can be given stock medications, such as
acetaminophen for high fever.
The partnership of school nurse, parents/guardians, and physicians, forming a circle
of support around the student is key to a successful school year, especially if a child
has special health needs. Most importantly, the school nurse is a child advocate
familiar with the complicated institutions of both education and healthcare. As a
member of the educational team, the school nurse can help parents/guardians and
the child navigate through these systems successfully.
HEALTH SERVICES DELIVERY
What are the legal parameters for practice for credentialed medical
assistive personnel in schools such as respiratory therapists, medical
assistants, and EMTs?
It is important that school districts are familiar with the practice laws for the specific
practitioner. For most of these practitioners, there is a restriction to practice only
under the direction of a "qualified” medical director or other healthcare provider
licensed by the Michigan State Board of Medical Examiners.
In the school setting, a medical assistant should be considered a lay person, unless
supervised by a physician who delegates tasks according to the Medical Practice Act.
Medical assistants, respiratory therapists, and EMTs should be considered unlicensed
assistive personnel (UAP), an unlicensed person in the school setting. They need to
follow the same protocols and procedures set forth for lay persons assisting with
health services, which includes the registered nurse assessing the UAP’s tier of
knowledge and skill. Supervision of the UAP who is providing delegated health
services is required. Supervision is defined in the Occupational Regulation Sections
of the Michigan Public Health Code, act 368 of 1978, Article 15, Part 161, General
Provisions as the licensed health professional overseeing the work of another
individual and requires that the licensed health professional provide documented
supervision. This supervision consists of 3 components:
• Training: the school nurse must be competent in the skill to train UAP.
• Communication: the UAP can contact the school nurse immediately with
questions/concerns.
• Evaluation: the school nurse will routinely evaluate the skills/technique of
trained UAP.
For additional questions, you can contact the Bureau of Health Professions.
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What is the role of the Licensed Practical Nurse (LPN) in school
settings?
MCL 333.17208 states that an LPN is a health profession subfile of the practice of
nursing which means that they must be supervised by a registered professional
nurse (RN), physician, or dentist.
Can you please explain specifically what "supervision" of an LPN
means?
Supervision is defined in the Occupational Regulation Sections of the Michigan Public
Health Code, Act 368 of 1978, Article 15, Part 161, General Provisions as the
licensed health professional overseeing the work of another individual and requires
that the licensed health professional provide supervision. Direct supervision requires
a registered professional nurse to be immediately available to coordinate, direct, and
observe firsthand another individual for whom the RN is responsible. The RN must
provide adequate supervision for those whom the RN is administratively responsible.
The supervising RN must use professional judgment and the nursing process when
determining the tier of supervision. The amount of supervision warranted will
depend on the setting in which care is provided, the training, experience and
capability of the individual being supervised, the needs of the clients being served,
and the availability of the RN. All licensed practical nurses must be supervised by an
RN or MD.
Return to TOC
What is required for schools to be able to provide care beyond soap,
water, Band-Aids, and ice?
Under Michigan law, medical treatments and/or medical procedures require a
doctor's prescription or doctor's order. When the requested service involved
requires one of these, the school/school nurse may NOT begin the services until the
requirement for a prescription or medical provider’s order is met. Having the
services of a school nurse is helpful since they are able, under law, to communicate
with the doctor, and take a verbal order for the medication or treatment (followed
by a written order) which a school administrator or unlicensed person may not.
What should a school/school nurse do if a student arrives at school
with no doctor's orders and the parent/guardian requests services?
The requested medical services or medication administration cannot be
accommodated by the school/school nurse until a healthcare provider’s order is in
place.
Communication and advance planning go a long way in assuring everyone’s roles
and responsibilities are understood. School staff does not want to be caught
unaware, or experience an adverse event, in which they are not prepared with the
information, equipment, or staff needed to respond to a student’s health condition.
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Hence, the parent/guardian should begin communicating with the school nurse as
soon as they know that their child may need health related services. If the
parent/guardian of a student served by special education, the parent/guardian
should ask if the nurse has been included in planning for their child. If you are a
school employee, make sure that you communicate with other staff as well as the
parent/guardian.
Can schools accept a licensed healthcare provider’s orders received
via email?
School nurses/schools should have a system to verify that the order originated from
the healthcare provider. An emailed order can be considered valid only if it contains
an electronic copy of the healthcare provider’s signature and the email address can
be confirmed. Without these criteria met, the email should be considered
unacceptable due to authentication issues.
Some options in this case are:
• The healthcare provider’s office can fax the order to the school with the
healthcare provider’s signature. Take precautions to maintain confidentiality.
• The school nurse (if available) can contact the healthcare provider’s office by
phone to verify the order (registered nurses are allowed to accept verbal
orders).
• The parent/guardian and/or healthcare provider’s office can deliver/mail a
hard copy of the order with the healthcare provider’s signature.
Can schools accept out-of-state-orders from a licensed healthcare
provider (HCP)?
If the students are being treated in Michigan pursuant to orders of a HCP in an
adjoining state, this is allowed under Section 16171 of the Public Health Code. This
provision allows an individual who resides in an adjoining state, who is authorized
under the laws of the other state to practice, to practice in Michigan without a
license, if they do not maintain an office in Michigan or designate a place to meet
patients or receive calls in Michigan.
Nurses and other staff acting in another state, are subject to the laws and
administrative rules in that state. Therefore, they should consult the laws and rules
of the state they are providing services in.
Does a healthcare provider need to sign off on every accommodation
detailed in the student’s Emergency Care Plan (ECP) or other
accommodation plans?
The healthcare provider plays a significant role on the team by providing accurate
and current medical information, providing the emergency protocol, and signing
the appropriate treatment and medication administration forms. The healthcare
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provider, however, is often unfamiliar with the day-to-day operations of the school
and is not in the position to recommend or to sign off on academic accommodations.
Must the school team accept all recommendations from a healthcare
provider?
Medical/therapeutic recommendations should be accepted by the school team unless
they are outside the acceptable standard of care. Suggestions and
recommendations that affect the educational program and school operations
from the healthcare provider should be welcomed and considered carefully,
however, they need to be decided on by the school team. Open communication
between the family, the school staff, and healthcare provider are recommended to
develop a plan that meets the individual student’s need and takes into consideration
each school’s unique environment. However, consideration should be given to any
suggestions and requests the provider has regarding the student.
Must a school nurse accompany students that have a history of
allergic reactions or have other health needs on field trips?
A school nurse who is familiar with the students’ health condition and treatment
may need to accompany a student if the school nurse determines that medical care
cannot legally or safely be delegated (School Sponsored Trips-The Role of the
School Nurse). The administration of epi-pens and medication/procedures for
other chronic health conditions can be carried out by adequately trained school
personnel, or even self-administered by the student, if this has been agreed upon
and planned for by the parents/guardians, physician, school administrator, and
nurse.
For this reason, school administrators, working with a school nurse, should create
procedures for how emergent situations are handled when a school nurse in not
present. The school nurse plays a key role here in facilitating communication
between the administrator and the staff so that all personnel are adequately trained
and aware of the expectations of them in cases of emergency. If a school does not
have the services of a school nurse, please see “Delegation vs. Training”.
How do I ensure a child’s safety during before and after-school
activities?
Students may be involved in several school-sponsored activities throughout the
year. It is extremely important that the supervising staff of any activity occurring
before, or after-school talk to the parent prior to the activity starting. School district
policies should include plans for access to ECPs and emergency medications and
supplies during all school sponsored activities. However, if the activity is taking
place in the school is not related to the school, check with the sponsor of the activity
about services provided. The sponsor is typically responsible for supporting student
health needs. Specific information about who will be responsible for health needs
should be included in “building use” agreements. This information should be shared
with all involved in the activity and especially the parents of students participating in
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the activity as arrangements for medical needs will need to be made outside of what
is already in place for the school day.
What are the requirements to make food substitutions for a
student when school meals are concerned?
If a student has a documented disability or medical issue that restricts their diet, the
school foodservice department must make the substitutions as listed by a
licensed medical professional (MD, DO, NP, PA) on a completed medical statement
form MDE Special Dietary Needs. If, however, a request for food substitutions is
made for a student without a documented medical issue, the school foodservice
department may make the substitutions listed on the medical statement form
signed by a recognized medical authority. Any substitution of this kind must fully
meet the reimbursable meal pattern.
It is the responsibility of the parent/guardian making the request to submit a
properly filled out and documented medical statement form. MDE Guidelines for
Food Allergies in Michigan Schools, Early Childhood and Education Programs
provides guidance for best practices. (See page 43).
Is it appropriate to discuss food allergies or other chronic health
condition accommodations in the student’s plan in front of other
parents and students?
NO, schools should maintain the confidentiality of student health information.
Parents may be informed of the general food allergy or other health condition
management plan without any reference to a particular child. With permission from
the parent of the student with life-threatening food allergies, it may be appropriate
in specific situations to share certain aspects of a student’s plan, such as the need
for allergy-alert classrooms, or alternatives to food celebrations in the classroom.
However, it is important to protect the family and student from discrimination and
harassment due to accommodations that need to be made.
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What care coordination is needed to achieve best results for students
with chronic health conditions?
Collaboration and cooperation are key elements in planning and implementing
successful management of student’s chronic diseases/health needs at school.
Students are more likely to succeed in school when the student’s school health team
and the student’s personal health care team work together create a circle of support
around the student with health needs.
Personnel may include:
School Health Team
Student
Parent/Guardian
School Nurse or other qualified Personnel
Principal and other administrators
504/Individualized Educational Plan (IEP)
Coordinator
Office Staff
Teachers
Guidance Counselor
Coaches
Other school staff members responsible for the
student
Personal Health Care
Team
Student
Parent/Guardian
Healthcare Provider
Nurse
Registered Dietician (if appropriate)
Health Care Educator in Chronic Disease
Collaboration between these two teams should result in each student with a health
condition/need having a Medical Management Plan (MMP), an Individualized Health
Plan (IHP), Emergency Care Plan (ECP) for medical treatment for chronic health
condition and an appropriate education plan (if needed).
• An MMP: Contains all aspects of routine and emergency care, developed by
the student’s personal health care team.
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• An IHP is a written plan developed to implement the student’s MMP:
o Developed by the school nurse (or other qualified personnel) in
collaboration with the student’s personal health care team and family
and incorporates assessment of school environment.
o Contains student-specific information.
o Reviewed by nurse (or other qualified personnel) and parents at
beginning of the year and periodically afterwards.
• An ECP is based on medical orders in the MMP and consists of a summary of
how to recognize and treat symptoms experiences.
o Should be given to all personnel responsible for the student (teachers,
coaches, bus drivers, lunchroom staff, etc.).
• An Education Plan, 504 Plan or IEP are developed as needed, not all
students with a chronic health condition need/will have one.
o The plans are written by team of school personnel, parents, and
appropriate coordinator for the school district.
How long is an MMP, IHP, ECP, Education Plan, 504 Plan, or IEP good
for?
Each of the plans are reviewed and updated annually and as needed throughout the
year.
What care coordination is required for students with health needs?
Standards of Care for Supporting Students with Health Needs in Michigan allow
students with chronic health conditions to be safe and supported by schools who are
following current law and best practice. Each student with a chronic health condition
is unique in his or her disease process, developmental and intellectual abilities, and
levels of assistance required for disease management.
• Supporting Students with Chronic Conditions at School: Standards of Care
• 21 Century Framework School Nurse Practice
• A Model for School Nurse Led Case Management (MASN/NASN may be
required)
• Translating Strategies into Actions to Improve Care Coordination for Students
with Chronic Health Conditions
• Chronic School Health Assessment Tool
What school staff training is required for students with health needs?
Provide 3 tiers of professional development training for school staff based on the tier
of responsibility the staff member will have on supporting students with health
needs. All staff should receive information on the health condition basics. Staff who
will have responsibility for daily support and emergency care for students with
should be provided training on management, trigger management, preventative
medications, and emergency response.
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• Trainings should be administered by a school nurse, medical professional, or
certified educator (or a qualified person designated by the local school
administrator if neither is available).
• Training should take place at the beginning of each school year and should be
repeated when a current student is newly diagnosed or when a student with
the health condition enrolls in the school. Refresher training is to be done as
needed.
• Trainings should be provided to classroom teachers, physical education
teachers, coaches, athletic directors, secretaries, administrative assistants,
playground aides, principals, facility and maintenance staff, food service staff,
paraprofessionals, and bus drivers based on three tiers of training.
There are 3 tiers of training. Each tier builds on the prior tiers.
• Tier 1 training is administered to all school personnel at the beginning of the
year.
o Tier 1 training is an overview of the health condition which includes:
how to recognize and respond to symptoms and who to contact for help
in an emergency.
• Tier 2 training is designed for school personnel who have responsibility for
identifying and responding to health-related emergencies the student may
experience throughout the school day. These staff members may include, but
are not limited to classroom, physical education, music, and art teachers, as
well as other personnel such as lunchroom staff, coaches, and bus drivers.
Tier 2 training content builds on content from Tier 1 with specific instructions
for:
o What to do in case of an emergency, roles and responsibilities of
individual staff members, and expanded overview of the health
condition.
o Procedures and brief overview of the operation of devices (or
equipment) commonly used by the student.
o Impact of on behavior, learning, and other activities.
o The student’s Individualized Health Care Plan (IHP), 504 Plan, IEP, or
other education plan.
o The student’s Emergency Care Plans and how to activate Emergency
Medical Services in case of an emergency.
o Tips and planning needed for the classroom and for special events.
o Overview of the legal rights of students with that health condition in the
school setting.
• Tier 3 training includes content from Tier 1 and Tier 2 and includes one or
more school staff members designated as trained personnel who will perform
or assist the student with required daily care tasks.
• See specific training resources for students with chronic diseases:
o Allergies (food)/ Anaphylaxis
o Asthma
o Cardiac (Project in Progress, contact State School Nurse Consultant)
o Diabetes
o Seizures
o Sickle Cell Disease (Project in Progress, contact State School Nurse
Consultant)
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What is a “Medical Emergency Response Team (MERT)?
Any child or adult can have a medical emergency in school. The Medical Emergency
Response Team (MERT) responds to both individual and building emergencies.
Unlicensed school personnel on the MERT are trained handle medical emergencies to
provide immediate and temporary care in the building until professional help arrives.
The purpose of the MERT is to be prepared and respond to medical emergencies
through training, drills, and practice. MERT members may include principals,
secretaries, paraprofessionals, teachers, teachers with special needs, school nurse,
P.E. teacher, and others. Team members are generally certified in CPR and First Aid
and are designated by the school administrator.
The MERT responsibilities include:
• Identify the emergency
• Implement Emergency Procedures
• Provide care
• Submit required reporting
• Debrief
Addendum to the 2002 Model Policy and Guidelines for Administering Medications to
Pupils at School Guidelines for Responding to an Anaphylaxis Emergency at School
What should a school nurse do if the health needs of one child do not
allow the school nurse to carry out all other job responsibilities?
The first step is for the nurse to perform a nursing assessment that outlines the care
required for the student to remain safely in school. This assessment should detail
those services that require nursing services and those that could be delegated to
someone else under the nurses’ supervision. This assessment will require
communication with parent/legal guardian and the licensed healthcare provider. If
the assessment finds that the services required for this student requires more time
than assigned, the school nurse should make their immediate supervisor aware of
the problem by notifying the supervisor in writing and suggesting that a meeting be
convened to remedy the situation. By informing the supervisor, the nurse goes on
record as having informed someone in a position to address the problem.
Some schools have hired additional medical staff and some have worked with
parents/guardians to make care arrangements such as a private duty nurse, or a
home health nurse. Any such arrangement should be reviewed by the district’s legal
counsel and documented in the form of a memorandum of understanding or other
type of agreement.
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LAWS
What federal and state laws, model policies, procedures, and
professional standards of practice direct administering health
services in schools?
• Michigan Public Health Code (PHC)
The PHC was written to promote and protect public health. It also legislates
how a healthcare providers practice. The PHC Act 368 of 1978, Part 172
Nursing defines a nurse’s practice.
• Michigan School Code (MSC)
The MSC was developed in 1976 and revised several times to provide
guidance to public
instruction and elementary and secondary schools.
• Michigan Department of Education School Nurse Certification
"School nurse certification" means that an interim, standard, or professional
school nurse certificate has been issued to a registered nurse by the MI state
board of education. The National Association of School Nurses also
recommends National School Nurse certification.
• Laws and Model Policies that Guide School Health Services Programs
in Michigan
This Laws and Model Policies document provides an overview of federal and
state laws that can establish parameters for policy options concerning
Michigan school health services. Resources (topics) are listed in alphabetical
order. Links to the specific federal laws are included. State laws that guide
school health services include the Michigan Revised School Code (designated
with 380 prefix) and the Michigan Public Health Code (designated with 333
prefix). These state laws are hyperlinked in this document to the specific area
in each of the legislative documents that best demonstrate the content being
highlighted. In some current cases, the Public Act is also included to better
leverage familiarity with the law.
• The Family Educational Rights and Privacy Act (FERPA)
Protects the privacy of student education records and applies to all schools
that receive federal funds.
• The Health Information and Portability and Accountability Act
(HIPAA)
Ensures privacy protections of individuals’ health information.
• Joint Guidance on the Family Educational Rights and Privacy Act
(FERPA) and the Health Information Portability and Accountability Act
The U.S. Department of Education and the Office for Civil Rights at the U.S.
Department of Health and Human Services released updated joint guidance in
December 2019 addressing the application of the Family Educational Rights
and Privacy Act (FERPA) and the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) Privacy Rule to records maintained on
students. The guidance clarifies for school administrators, healthcare
professionals, families, and others how FERPA and HIPAA apply to education
and health records maintained about students.
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DELEGATION OF NURSING CARE IN SCHOOLS
What’s the difference between delegation and training?
Because not all schools elect to provide school nurse services, it is important to
consider how children with health concerns needs are met in schools in Michigan.
School administrators often seek the assistance of nurses employed in other districts
or from the community to provide training for medication administration, or other
treatment for children (i.e., trach care, etc.). This sets up a predicament for the
nurse asked to provide training when they know they will be unable to provide
ongoing supervision. The nurse that receives a request to provide “training” must
carefully consider whether it is prudent to do so and whether children will be safely
cared for without a nurse to provide supervision of the staff trained.
In regards to medication administration, the Michigan School Code allows for the
school administrator to assign the task of medicine administration to unlicensed
staff. This has been interpreted to include any medication, including
injectables. Under these circumstances, it becomes the responsibility of the nurse
asked to provide training, to work with the school administrator to develop a plan so
that the staff designated to administer the medication are appropriately trained and
prepared to handle the scenarios that may result. The nurse must verify staff
competency in carrying out the procedure, assure patient safety, and inform the
school administrator if the task needs to be assigned to someone else. This is not
"delegation" by the nurse. The school administrator has assigned the task. The
nurse is ensuring that the people assigned the task are trained, and prepared, and
that the student will receive the best possible care. The issue with this scenario is
that medication orders should in best practice be reviewed by a school nurse for
accuracy and to make sure they are safe and often school staff may have questions
about an order or a medication. Consideration needs to be given to who will be
available to the UAP in those cases.
Before agreeing to train an unlicensed staff person to perform what would
be considered a nursing task, if determined by the nurse, the task must be
delegated, and the following applies:
Delegation and Supervision
Delegation is defined in the Occupational Regulation Sections of the Michigan Public
Health Code, Act 368 of 1978, Article 15, Part 161, General Provisions as
“authorization granted by a licensee to a licensed or unlicensed individual to perform
selected acts, tasks, or functions which fall within the scope of practice of the
delegator and which are not within the scope of practice of the delegatee and which,
in the absence of the authorization, would constitute illegal practice of a licensed
profession.” In their General Rules, Part 1 - General Provisions the Michigan Board
of Nursing have promulgated specific administrative rules about delegation which
are summarized below.
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Supervision of the UAP by the nurse who is delegating the task is required.
Supervision is defined in the Occupational Regulation Sections of the Michigan Public
Health Code, Act 368 of 1978, Article 15, Part 161. General Provisions as the
licensed health professional overseeing the work of another individual and requires
that the licensed health professional provide supervision. This supervision consists of
3 components:
• Training- the school nurse must be competent in the skill to train UAP.
• Communication- the UAP can contact the school nurse immediately with
questions/concerns.
• Evaluation-the school nurse will routinely evaluate the skills/technique of trained
UAP.
The RN must fulfill the requirement for continuous availability. Occupational
Regulation Sections of the Michigan Public Health Code, Act 368 of 1978, Article 15,
Part 161, General Provisions, 333.16215 ties delegation to supervision. You cannot
delegate without supervising.
There may situations in which, upon assessment, the nurse determines the
task involved cannot be delegated and must be performed by a licensed
nurse. That determination must be reported to the school administrator in
order that the school can provide the necessary services the child requires.
What nursing services are delegable?
The school nurse must first determine if the task can be delegated using criteria set
forth in Michigan law, in professional standards and in assessment of the unique
characteristics of the individual student requiring nursing services. A nursing task
may be determined to be delegable and assigned to be performed by nursing
• ONLY a RN may delegate nursing, functions, or tasks. LPN’s may not
delegate.
• LPN’s must be supervised by the RN, physician, or dentist.
• The RN delegates tasks – not responsibility/accountability for patient care.
• The RN delegates from her/his scope of practice.
• The RN cannot delegate acts, tasks, or functions that are not within her/his
scope of practice.
• The RN determines whether the delegate has the knowledge/skill to do a
specific task.
• The RN determines whether the task for a specific client can be performed
safely and competently for the specific client.
• The RN supervises the performance.
• The RN shall bear ultimate responsibility for the performance of nursing
acts, functions, or tasks performed by the delegate within the scope of
delegation. Mich, Admin, Code R338.10104
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assistive personnel (UAP) under the supervision of a registered nurse (RN) if the
individual situation meets all the criteria and in the nurse’s judgment, it is safe to do
so. Michigan School Health: Delegation (2021). Professional & Legal Regulations -
Michigan Nurses Association (minurses.org).
What nursing services are non-delegable?
Not all nursing tasks may be delegated. Certain nursing services may only be
performed by an RN or Licensed Practical Nurse (LPN) under the supervision of an
RN. Should a nursing task fail to meet the criteria for delegation, the nursing
task/procedure must be performed by the RN or LPN under the supervision of an RN.
Examples of these tasks may include a complex tracheotomy suctioning,
tracheotomy tube, inner cannula change or replacement, any medication that
requires calculation of the dose unless the specific method of calculation is provided,
assessment before or after administration, and certain medications given by
injection. Any service needing nursing assessment and/or performed on “an as
needed basis” is not delegable. It is important to note that a specific task is only
delegated for a specific student, therefore, a procedure that is delegable for one
student may not necessarily be delegable for any other student.
Michigan law does not delineate which nursing tasks can be delegated, though based
on the nurse’s assessment and judgment examples of those tasks may include,
calculation of insulin doses, providing appropriate training on the student’s specific
method of calculation is provided, pharmacy or prescriber prepared hand-held
inhalant medication administration, clean intermittent/non-complex bladder
catheterization, student specific emergency medications, and assembly of supplies
and supervision of student finger stick for blood sugar with appropriate training of
the individual student specific needs. Michigan School Health: Delegation (2021).
What resources in this area are available for the school nurse to use?
• Professional & Legal Regulations - Michigan Nurses Association
• Laws and Model Policies that Guide School Health Services Programs in
Michigan: A Resource for School Nurses. (See Delegation and Scope of
Practice).
• Michigan School Health: Delegation
• NASN Nursing Delegation in the School Setting
• NASN Principles for Practice: Nursing Delegation to Unlicensed Assistive
Personnel in the School Setting 2nd Edition
• Delegation in the School Setting: Is it Safe Practice?
• National Guidelines for Nursing Delegation
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ADMINISTRATION OF MEDICATION
What conditions must be met to administer medication in schools?
A medication order signed by a healthcare provider with instructions for
administering, storing, and disposing of medication for an individual student may be
faxed, emailed to the school, or brought in the parent. All prescription medications
should be in their original, child-proof containers and include the following:
• The child's first and last name.
• The physician's name and contact information.
• The filled date and expiration date on the container.
• Instructions for administering, storing, and disposing the medication.
How are student’s medications stored in school?
Michigan policies for storage and access to medications in school are as follows:
• All medication shall be kept in a labeled container as prepared by a pharmacy,
physician, or pharmaceutical company with the pupil's name, the name of the
medication, dosage, and the frequency of administration.
• Medications (except emergency medications) shall be stored in a school
location that is kept locked.
• Emergency medications should be stored in an area readily accessible to the
individual designated to administer them.
• All controlled-substance 1 medications will be counted and recorded upon
receipt from the parent/guardian. The medication shall be recounted on a
regular basis (monthly or bi-weekly) and this count reconciled with the
medication administration log/record. Control medications must be double
locked in a secure area.
• Medications stored in a refrigerator must be stored in a locked container
separate from food items. (Michigan School Health: Medication
Administration, 2022).
Who can administer medications to students in schools?
Michigan School Code Section 1178 REVISED (1995) states “a school administrator,
teacher, or other school employee designated by the school administrator” or
“licensed registered professional nurse” may administer medication. The Michigan
School Code allows for the school administrator to assign the task of medicine
administration to unlicensed staff. School districts are accountable for developing
policies and procedures for safe administration of medication. The Michigan
Department of Education developed a Model Medication Policy for schools as
required by law. School districts should adopt policies regarding the administration
of medication that is in alignment with the state guidelines and this policy should be
reviewed regularly. These policies shall be consistent with federal and state laws,
nursing practice standards and established safe practices. The Individuals with
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Disabilities Education Act, and Section 504, mandate schools receiving federal
funding to provide “required related services” including medication administration.
Every school district must have a clear and concise written policy for administration
of medication that includes initial and annual training provided by a licensed
professional registered nurse/healthcare provider for all unlicensed school personnel
who are administering medication.
A school nurse is the professional that has the knowledge and skills required for
delivery of medication, the clinical knowledge and understanding of the student’s
health, and the responsibility to protect the health and safety of students. They are
also a valuable resource in the development of school district policies/procedures.
What are the common conditions in schools for which medication is
given?
The most common conditions that require medication in schools are, food allergies,
asthma, diabetes, seizures, and attention deficit hyperactivity disorder.
Can over-the-counter medications be administered at school without
a healthcare provider’s order?
In some cases, yes. Public Act 243, 2018 states, if the school or school district
policy does not have a policy that differs, a student of a public school or nonpublic
school may possess (self-carry) and use (self-administer) a United States Food
and Drug Administration (FDA) approved, over-the-counter topical substance at
school, on school-sponsored transportation, or at any activity, event, or program
sponsored by the student’s school is participating if all the following conditions are
met:
• The student is a minor.
• The student has written approval to possess and use the United States FDA
approved, over-the-counter topical substance from the student’s parent or
legal guardian.
• The principal or other chief administrator of the student’s school must have
written approval on file.
The use of OTC asthma medication is not considered best practice and should not be
encouraged in school.
What rescue or quick relief medications are given in schools?
The student’s emergency care plan must be followed when administering these
medications.
• Allergies: epinephrine given by an epinephrine auto injector.
Note: A new epinephrine delivery route, a nasal spray, “Neffy”, is under
review by the FDA. It will offer a new treatment option for people who prefer
a needle-free way to treat anaphylaxis (April, 2023).
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• Asthma: asthma quick-relief medication given by an inhaler or medication
administered via a nebulizer.
• Diabetes: Glucagon injection is given for low blood sugar and insulin is given
to maintain blood sugar.
• Opioid Overdose: Naloxone spray is given as a nasal injector. Naloxone is
also available as an injectable which is given in the muscle. In March, 2023
the U.S. Food and Drug Administration approved Narcan, 4 milligrams (mg)
naloxone hydrochloride nasal spray for over-the-counter (OTC),
nonprescription, use.
• Seizures: Diastat
®
-a diazepam rectal gel, Nayzilam
®
- a midazolam nasal spray
and Valtoco
®
- a diazepam nasal spray.
Are all schools required to stock epinephrine?
YES. Epinephrine Auto-Injector Public Act 186 & 187 of 2013 (EAI) requires stock
epinephrine for public schools K-12 students and any other individuals on school
grounds who are believed to be having an anaphylactic reaction. This mandate does
not apply to private schools, Head Start, and/or Early Childhood Centers.
How do schools obtain or replenish stock epinephrine in Michigan?
For EpiPen: Go to EpiPens for Schools and follow the instructions to download forms
on One Option: How to Obtain/Replenish Stock Epinephrine in Michigan.
• Download Forms.
• Print the form you need: Free Certification Form-for a school to get the two
initial Epi pens for the year or to replace expired ones.
• Replenish Certification Form: When you use an EpiPen for anaphylaxis at
school and need a replacement.
• PLUS, Epinephrine Standing Order Protocol Form.
• Email completed Forms to Julie Formella at jformella@annarborallergy.com
OR you can fax the forms to Julie at Dr. Harvey Leo’s office: 734-434-6317
(They receive a high volume of faxes, so email is preferred).
• Send the prescription with a copy of the above form to: Certification and
Discount Forms: Fax the completed Form and a copy of a valid EpiPen ®
Auto-Injector prescription to BioRidge Pharma, LLC Fax: 973-718-4328.
• Call 973-845-7600 afterward to verify that everything was received by them.
ADDITIONAL OPTIONS
• Consider School Based Health Center Providers for the prescription
• Good RX for a coupon to fill prescription. Save your receipt
• Auvi-Q Public Access provides a School Nurse Toolkit and epinephrine auto-
injector trainers
• Provides epinephrine auto-injector trainers (Oakland County Health
Department, 2023)
CVS offers a generic EAI for app. For a discount at
https://www.cvs.com/content/epipen-alternative. At this point a local CVS can only
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22
fill prescriptions for patients not schools. Check with a pharmacy manager at a local
CVS to see if they can provide generic EAI to schools.
Another suggestion worth trying is to check out online medication coupons to see if
the previously mentioned companies/distributors can accept them from a school for
a reduction in EAI price [e.g., GoodRx, Medical Assistance Tool and Needymeds].
Advise your school administrator when epinephrine is given so the information can
be entered into the School Infrastructure Data Base (CEPI). This count should
reflect the total number of instances where an epinephrine auto-injector was used to
a pupil at the school. The count also includes all instances of administration,
including individuals with or without a previously known severe allergy, and those
using personal or school stock of Epinephrine Auto Injectors.
How do school nurses/schools obtain epinephrine auto-injector
trainers?
The following companies provide epinephrine trainers:
• Auvi-Q
• Adrenaclick
• Amneal
• Epi Pen
Who can administer an epinephrine auto-injector or other emergency
medication in schools?
If any trained staff member determines that an allergic reaction is potentially life-
threatening, the staff member will administer epinephrine at the direction of the
school nurse (or designee) and according to the standing order and/or emergency
action plan (ECP) for the student. It is recommended that ALL school staff be
trained in recognition of the signs and symptoms of an allergic response, and in the
safe and proper use of epinephrine premeasured auto-injection devices. This
training should be reviewed and updated every 2 years.
Are school staff protected if they administer stock epinephrine or
other emergency medications in schools?
Sec. 1178. (1) Subject to subsection (2), states a school administrator, teacher, or
other school employee designated by the school administrator, who in good faith
administers medication to a pupil in the presence of another adult or in an
emergency that threatens the life or health of the pupil, pursuant to written
permission of the pupil’s parent or guardian, and in compliance with the instructions
of a physician, physician’s assistant, or certified nurse practitioner, or a school
employee who in good faith administers an epinephrine auto-injector to an individual
consistent with the policies under section 1179a, is not liable in a criminal action or
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for civil damages as a result of an act or omission in the administration of the
medication or epinephrine auto-injector, except for an act or omission amounting to
gross negligence or willful and wanton misconduct.
Are schools required to stock Narcan?
A school board may require that in each school it operates, there are not fewer than
two employees who have been trained in the appropriate use and administration of
an opioid antagonist. A school board that requires an employee to be trained, shall
ensure the training has been approved by a licensed professional nurse. See the
MDE Addendum to the 2002 Model Policy and Guidelines for Responding to an Opioid
Related Overdose at School.
In March of 2023, the U.S. Food and Drug Administration approved Narcan, 4
milligrams (mg) naloxone hydrochloride nasal spray for over-the-counter (OTC),
nonprescription, use – the first naloxone product approved for use without a
prescription.
What paperwork must be in place for a student to possess/self-
administer medication at school or school sponsored activities?
Although individual school district forms, policies, and procedures may vary
regarding possession and self-administration of medication in school, the following is
required for self- possession of emergency medications:
• Current physician prescription.
• Written treatment plan from the physician including a statement that the pupil
can self-administering the medication under the treatment plan.
• Parent permission.
• A school nurse will determine whether a student who self-administers
medication is responsible to self-carry their medication. The developmental
ability of the student, the need to have ready access to emergency medication
and the safe storage of medication must be considered when making this
decision.
• These documents should be renewed yearly, or as any changes in the
student’s treatment plan are made.
Can the school district tell students they cannot carry their
epinephrine auto-injector or other emergency medications during
school or school related events?
If the family does not provide the required paperwork listed above or the student
fails to follow school policies regarding possession and self-administration of
medication, the student may be denied the right to carry and self-administer
medication at school. Safety of all students is the ultimate goal.
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What can a school do if the parent does not provide emergency
medication or emergency care plans?
Every effort should be made to ensure that required emergency medication be
available for the student. The guiding principle is the safety of the child. The
school/school nurse can assist the parent with identifying resources to access
medication. The child’s physician may be able to provide a supply for the child at
school. Parents should be advised that without emergency instructions or
medication, the school has no option but to call 9-1-1 and the student will be
transported to the hospital if an emergency arises. If resistance from the parent is
still encountered after all efforts by the school to assist the parent have been
exhausted, it may be necessary to involve child protective services. Follow school
guidelines in this case.
What should the school nurse do regarding preparing medication for
field trips/school sponsored events?
The Michigan Department of Education developed a Model Medication Policy for
schools. As required by law, the district should have in place a medication policy
that follows the state guidelines, and this policy should be reviewed regularly. The
school district policy should address field trip medication.
A parent/guardian may request from the pharmacy that a single dose of medication
for a field trip be placed in a properly labeled prescription bottle or OTC container to
be given on the school-sponsored trip by school personnel.
The employee assigned the task of administration of medication to the student on
the field trip/ school sponsored event should be trained in medication administration
and will carry the child’s medication in the original container on the field trip/school
sponsored event. A documentation mechanism should be developed as well, to
include in the student's medication administration record.
What resources on Medication Administration are available for the
school nurse to use?
• MDE Model Policy and Guidance for Administering Medication to Pupils at
School
• Michigan School Health: Medication Administration
• FAQ’s Epinephrine Auto-Injector Act 186 & 187
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses (See sections: Anaphylaxis Non-Specific
Epinephrine, Asthma, Medication, and Opioid Antagonist)
• Procedures For Administration of Medications for Field Trips
• NASN’s Medication Administration in Schools Toolkit (membership required)
• NASN’s Medication Clinical Guidelines (MASN/NASN membership required)
• Michigan School Health: Medication Administration
• School Sponsored Trips – The Role of the School Nurse
• Naloxone in the School Setting (NASN Position Statement)
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What medication administration training is available for school staff?
MASN’s Safe and Legal Support of Student’s Medication Needs (includes Epinephrine
Auto Injector & Naloxone) provides information, update and review training by an
R.N., Physician, Nurse Practitioner, or Physician Assistant familiar with school health
policies and laws to staff administering medication in the school setting. Participants
will become knowledgeable and skillful in the task of medication administration.
Training should be comprehensive and ongoing. (MASN membership required).
CHRONIC CONDITIONS
How are chronic conditions managed in the school setting?
Health services may be required for students with chronic health conditions to
ensure their healthcare needs are met, requirements of relevant federal and state
laws are met, and students can fully participate in school and school-sponsored
events. The healthcare needs of children with chronic illness can be complex and
continuous and includes both daily management and addressing potential
emergencies. The Center for Disease Control affirms schools can help students with
chronic health conditions by providing services through a school nurse or at a
school-based health center. School health services staff can help students stay at
school safely and ready to learn.
School nurses provide a skills-based approach, translating strategies into actions to
improve the care for students with chronic health conditions.
Supporting Students with Chronic Conditions at School: Standards of Care allows
students with chronic health conditions to be safe and supported by schools who are
following current law and best practice. Each student with a chronic health condition
is unique in their disease process, developmental and intellectual abilities, and tiers
of assistance required for disease management.
What resources are available to assist the school nurse with students
with chronic conditions?
• Managing Chronic Conditions in School
• Chronic School Health Assessment Tool
• Translating Strategies into Actions to Improve Care Coordination for Students
with Chronic Health Conditions
• Research Brief: Addressing the Needs of Students with Chronic Health
Conditions: Strategies for Schools
• School Nurse Training Resources for Common Chronic Conditions – Rescue
Medications
• Research Brief: Chronic Conditions and Academic Achievement
• A Model for School Nurse Led Case Management: Guidance and Resources to
Support the School Nurse in Providing Case Management for Students with
Chronic Health Conditions.
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ALLERGIES (FOOD)/ANAPHYLAXIS
Additional Information on Allergy/Anaphylaxis:
Medication Administration
• Requirements, storage, rescue medication, stock epinephrine and other
medications, orders via email, out of state orders, self-carry/self-
possession, field trips, school nurse resources, and actions when parents
do not provide emergency medication.
Health Services Delivery
• Supervision of LPN, students without licensed healthcare provider orders,
orders via email, out-of-state orders, emergency care plans, chronic health
plan accommodations requirements, student safety during school activities,
required food substitutions, staff training, care coordination, and Medical
Emergency Response Teams, (MERT).
Field Trips
• What a when child goes on a field trip, out of state filed trips, requirements
for school nurse and prepared medication, and who may accompany
students on field trips.
What can schools do to assist children who have food allergies?
First and foremost, school districts should develop a policy on food allergies and how
to handle them. The school nurse is skilled and knowledgeable and can assist with
the development of this policy. The CDC’s Voluntary Guidelines for Managing Food
Allergies in Early Care and Education and Early Care Programs, assists School
Boards, School Administrators, and staff on actions to take when developing plan to
deal with allergies in schools.
• How to Create and Maintain a Healthy and Safe Educational Environment is
discussed on page 39.
• Recommended Practices for Reducing the Risk of Exposure to Food Allergens
and Responding to Food Allergies in Schools and Early Care Education
Programs chart is located on page 42.
The National School Board Association document, Safe at School and Ready to
Learn: A Comprehensive Policy Guide for Protecting Students with Life-Threatening
Food Allergies, also guides schools on policy development for allergies in schools.
Can food be restricted from a classroom?
In some situations, it may be reasonable on a case-by-case basis, to request that
students do not bring foods containing an allergen into the classroom, especially for
younger children who eat meals in the classroom. Some students with allergies may
require a Section 504 Plan. In a school setting, a Section 504 Plan ensures eligible
students with disabilities have equal access to education. (See Section 504 Plans)
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When a classroom is designated as a “peanut alert” or “allergen-
aware” area and a parent complains that his/her child likes peanut
butter crackers for snack, how should I respond?
All children have the right to learn in an environment that is safe. It is sometimes
necessary to designate a classroom as “peanut or other allergen-aware” area (thus
asking that food items containing the allergen not be brought into the classroom) to
reduce the risk of accidental exposure for a particular student. Some children will
react if they ingest a particular allergen and others will react in varying degrees by
touching or inhaling it. Even a young child with an ingestion-only allergy might react
if he/she touches the allergen and subsequently puts his/her fingers in his mouth,
nose, or eyes. Early elementary classrooms are busy places with many centers such
as sand/water tables, puppet theaters, and toy kitchens where the risk of exposure
is great. Although the peanut-alert designation may be difficult for another child, it
does present an opportunity for you to teach all children about understanding and
cooperation in meeting the needs of their peers.
The terminology, “peanut-free” is not promoted as it may be misleading and provide
a false sense of security. It is impossible to always provide an absolute allergen free
environment in the school setting and therefore preferable to use terms such as
“Pals” tables, “allergen aware” areas.
If a child unexpectantly brings in a treat for the class, and it is unclear
as to whether the treat contains allergens, should the treat be given
to a child with an allergy?
Never serve any food item to a student with a severe allergy that has not been
approved or provided by the student’s parent or guardian. The teacher, other
parents, or school staff should not determine that food items are acceptable to be
served to students with severe food allergies.
Is it appropriate to use classroom manipulatives that involve food
allergens?
Using classroom manipulatives that contain allergens may prevent a particular child
from safely and equally participating in a class activity. As a result, teachers should
work with students and parents to ensure that all students can fully participate in
the activity. This may require the teacher to utilize manipulatives free from any
offending allergens. The extent of the child’s allergy, and his/her age and maturity
tier should be taken into consideration.
How can a child safely participate in school meal programs (breakfast
and lunch)?
Collaboration with food service staff is essential to assist the student with life-
threatening food allergies to participate in the school meal program. With
documentation from the student’s health care provider, meal substitutions can be
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made to ensure that students are provided with food choices that avoid certain
foods.
Can hand sanitizer be used to clean student’s hands?
Yes, if soap and running water is not available. Be aware hand sanitizers may not
remove all food proteins and may in fact spread these more easily. Rigorous hand
washing with soap and water is the most effective method for washing student’s
hands.
What are the requirements to make food substitutions for a
student when school meals are concerned?
If a student has a documented disability or medical issue that restricts their diet, the
school foodservice department MUST make the substitutions as listed by a
licensed medical professional (MD, DO, NP, PA) on a completed medical statement
form MDE Special Dietary Needs. If, however, a request for food substitutions is
made for a student without a documented medical issue, the school foodservice
department MAY make the substitutions listed on the medical statement form
signed by a recognized medical authority. Any substitution of this kind must fully
meet the reimbursable meal pattern.
It is the responsibility of the parent/guardian making the request to submit a
properly filled out and documented medical statement form. Voluntary Guidelines for
Managing Food Allergies in Schools, Early Childhood and Education Programs. (See
page 43).
What resources are available for the school nurse to use to support
their students with allergies (food)/anaphylaxis?
• Michigan Department of Education Food Allergy Guidelines for MI Schools
addresses accommodations, medication, emergencies, professional
development for staff and parent responsibilities.
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
• MDE Allergies and Anaphylaxis Toolkit
• CDC Food Allergies in School Toolkit
• FAQ’s Epinephrine Auto Injector Public Act 186 &187
• NASN’s Allergies and Anaphylaxis provides multiple resources on Sample
Planning, Policies, Practice Forms School Personnel Training and Education
Resources for school nurses.
• Voluntary Guidelines for Managing Food Allergies in Schools and Early
Childhood Programs
• Food Allergy and Anaphylaxis Emergency Care Plan
• Allergy and Asthma School Health Resources
• Sample Accommodations for 504/IEP/IHP
Frequently Asked Questions
School Health Services/School Nursing
29
ASTHMA
Additional Information on Asthma:
Medication Administration
• Requirements, storage, rescue medication, stock epinephrine and other
medications, orders via email, out of state orders, self-carry/self-
possession, field trips, school nurse resources, and actions when parents
do not provide emergency medication.
Health Services Delivery
• Supervision of LPN, students without licensed healthcare provider orders,
orders via email, out-of-state orders, emergency care plans, chronic health
plan accommodations requirements, student safety during school activities,
required food substitutions, staff training, care coordination, and Medical
Emergency Response Teams, (MERT).
Field Trips
• What a when child goes on a field trip, out of state filed trips, requirements
for school nurse and prepared medication, and who may accompany
students on field trips.
What can schools do to assist a student with Asthma?
The Michigan Department of Education (MDE) has a Model Policy for Supporting
Students with Asthma in Schools. MDE believes that a comprehensive school policy
for asthma can create a learning environment that is safe and supportive, improves
attendance and participation in activities, and promotes academic success and
wellbeing. This policy builds on existing asthma best practices, including Michigan’s
Inhaler and Epinephrine Auto-Injector Law, the Whole School, Whole Community,
Whole Child Model, and the School-Based Allergy, Asthma, and Anaphylaxis
Management Program , as well as national strategies from the Centers for Disease
Control and Prevention (CDC), the National Asthma Education and Prevention
Program (NAEPP), and the United States Environmental Protection Agency (EPA).
This policy also addresses the core tenets included in the Consensus Statement of
the Core Tenets of Chronic Condition Management in Schools and, if fully
implemented, meets the standards of care outlined in Supporting Students with
Asthma in School: Standards of Care. Return to TOC
What resources are available for the school nurse to use to support
their students with asthma?
• Michigan Department of Education (MDE) Model Policy for Supporting
Students with Asthma in Schools
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses Asthma Initiative of Michigan for Health Lungs
Get Asthma Help
• Managing Asthma in the School Environment
Frequently Asked Questions
School Health Services/School Nursing
30
• The School Based Allergy, Asthma & Anaphylaxis Management Program:
Comprehensive Asthma Education Resources
• Michigan Inhaler Fact Sheet
• Resources for Health Professionals: School & Childcare Providers
• Managing Asthma: A Guide for Schools (US Department of Health & Human
Services)
• Managing Asthma in Schools: A Guide for Schools
• Asthma Management Guidelines: Focused Update: 2020
• Allergy and Asthma School Health Resources
• The School-Based Allergy, Asthma and Anaphylaxis Management Program™:
Comprehensive Asthma Educational Resources
• NASN Asthma Resources
• Asthma Action Emergency Action Plan
• School Education Packets
CARDIAC CONDITIONS
Additional Information on Cardiac Conditions:
Medication Administration
• Requirements, storage, rescue medication, stock epinephrine and other
medications, orders via email, out of state orders, self-carry/self-
possession, field trips, school nurse resources, and actions when parents
do not provide emergency medication.
Health Services Delivery
• Supervision of LPN, students without licensed healthcare provider orders,
orders via email, out-of-state orders, emergency care plans, chronic health
plan accommodations requirements, student safety during school activities,
required food substitutions, staff training, care coordination, and Medical
Emergency Response Teams, (MERT).
Field Trips
• What a when child goes on a field trip, out of state filed trips, requirements
for school nurse and prepared medication, and who may accompany
students on field trips.
Return to top
What are a school district’s responsibilities when dealing with
students with cardiac conditions including cardiac emergencies at
school?
School personnel need to be prepared to provide care to students with cardiac
conditions including cardiac emergencies at school and at all school-sponsored
activities in which a student with a cardiac condition participates. Public Act 12 of
2014 mandates that every K-12 school shall adopt and implement a cardiac
Frequently Asked Questions
School Health Services/School Nursing
31
emergency response plan for the school. The cardiac emergency response plan shall
address and provide for at least all the following:
What is a Cardiac Response Plan?
The Cardiac Response Plan is driven by (Fire Prevention Code Section 29.19 PA 12 of
2014) and requires schools to address and provide for at least all the following:
• Use/regular maintenance of automated external defibrillators, if available.
• Activation of a cardiac emergency response team during an identified cardiac
emergency.
• A plan for effective/efficient communication throughout school campus.
• If the school includes grades 9 to 12, a training plan for the use of an
automated external defibrillator and in CPR techniques.
• Incorporation/integration of the local emergency response system and
emergency response agencies with the school's plan.
• An annual review and evaluation of the cardiac emergency response plan.
Can your Medical Emergency Response Team (MERT) serve as the
Cardiac Emergency Response Team as required by law?
Yes, the MERT Team can be trained to respond to any medical emergency, including
a cardiac emergency.
Are school staff/students required to have CPR training?
Yes. Requirements for the Initial Certification of Michigan Teachers. Training must
be documented and these records must be saved according to the Michigan Records
Retention Schedule #2.
• TEACHERS: Fully online courses are not acceptable; learning First Aid and
Adult & Pediatric CPR requires demonstration and practice. Blended courses
(online, combined with traditional face-to-face) and hybrid courses (web-
based, live video instructor training plus traditional) are permissible modes for
completing CPR and First Aid when available through the providers specified
within this guidance.
• In-state candidates must provide the educator preparation provider (EPP)
with the actual card(s) indicating the completion of approved courses. Out-of-
state candidates provide the Michigan Department of Education (MDE) with
copies of CPR and First Aid card(s) with application for a Standard Teaching
Certificate.
• Students are required one-time CPR and AED instruction for pupils enrolled in
grades 7 through 12. CPR Instructions in Schools, Revised School Code.
Physical Limitation Exemption
• MCL 380.1531d makes an allowance for educators who are unable to fulfill
CPR/First Aid requirements due to physical limitations. Teacher certification
candidates must provide written, dated, and signed documentation on
letterhead from a physician/health care provider to be considered for an
exemption from CPR/FA.
Frequently Asked Questions
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32
• In-state candidates should provide the above-mentioned documentation to the
EPP where they are enrolled. Out-of-state candidates provide documentation to
MDE through the certificate application process.
What is involved in developing a Heart Safe School Program?
The MI HEART Safe School Award Program was created to support school
communities’ efforts to prevent Sudden Cardiac Death in Youth with inherited
sudden cardiac arrest syndromes and increasing the awareness of how to recognize
the signs of a sudden cardiac arrest and respond quickly. Important questions for
schools to consider are:
• Does your school have a cardiac emergency response plan?
• How many students and staff can recognize the symptoms of cardiac arrest
and know how to get help “on the way, right away”?
• Who knows CPR in your school and is ready to use it when necessary?
• Where are the automated external defibrillators (AEDs) located in your school
building, are they properly maintained and inspected, and who knows how to
use them?
Project Adam affiliate sites assist schools and communities in establishing a
practiced plan to respond to a sudden cardiac arrest. They provide the
foundation for a school to develop and sustain their program, including planning
templates, a reference manual, and one-on-one consultation.
What is Sudden Arrhythmia Death Syndrome (SADS)?
SADS is a genetic heart condition that affects the heart’s electrical system and can
cause sudden stoppage of heart. SADS effects both young and healthy people.
Schools are required to have a Cardiac Response Plan to be prepared for a SADS
event.
What resources are available for the school nurse to use to support
students with cardiac conditions?
Resources include:
• Supporting Students with Cardiac Conditions in Schools Standards of Care
Including Training Standards (Training Toolkit and Checklist). (Project in
Process)
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
• SADS School Nurses (Information for School Nurse IHP’s)
• Sudden Cardiac Arrest in Schools: Planning and Management for School
Nurses
• School Health Care Plans for Cardiac Conditions
• Challenges Faced by Parents of Children with Congenital Heart Disease
• Project Adam
• Cardiac Emergency Response Planning for Schools
Frequently Asked Questions
School Health Services/School Nursing
33
• MI Heart Safe Schools
• Approved CPR & First Aid Providers
DIABETES
Additional Information on Diabetes:
Medication Administration
• Requirements, storage, rescue medication, stock epinephrine and other
medications, orders via email, out of state orders, self-carry/self-
possession, field trips, school nurse resources, and actions when parents
do not provide emergency medication.
Health Services Delivery
• Supervision of LPN, students without licensed healthcare provider orders,
orders via email, out-of-state orders, emergency care plans, chronic health
plan accommodations requirements, student safety during school activities,
required food substitutions, staff training, care coordination, and Medical
Emergency Response Teams, (MERT).
Field Trips
• What a when child goes on a field trip, out of state filed trips, requirements
for school nurse and prepared medication, and who may accompany
students on field trips.
Return to top
Does a school have to hire a registered nurse for a student with
diabetes?
Diabetes management in children and adolescents requires complex daily
management skills and health services must be provided to students with diabetes
to ensure their safety in the school setting and to meet requirements of federal laws.
Managing diabetes at school is most effective when there is a partnership among
students, parents, school nurse, health care providers, teachers, counselors,
coaches, transportation, food service employees, and administrators. A school
nurse provides the health expertise and coordination needed to ensure cooperation
from all partners in assisting the student toward self-management of diabetes
(NASN, 2017). Each student with diabetes is unique in their disease process.
It is recommended that if a child with diabetes attends school, a school nurse should
conduct a nursing assessment and develop an individualized plan for that child that
outlines the care required for the student to remain safely in school. This
assessment should detail those services that require nursing services and those that
could be delegated to someone else under the nurses’ supervision. This assessment
will require communication with parent/legal guardian and the licensed healthcare
provider. If the assessment finds the services required for this student can be
adequately handled by unlicensed school staff, training would need to take place.
The State Board of Education Approved Model Policy on the Management of Diabetes
in the School Setting states that all school personnel should receive training about
Frequently Asked Questions
School Health Services/School Nursing
34
diabetes and how to manage it. However, that training should be broken down into
different tiers depending on the responsibility of each staff member towards the
student with diabetes. The training should be administered by a school nurse or
certified diabetes care and education specialist (or a qualified person designated by
the local school administrator if neither are available). The school nurse plays a key
role here in facilitating communication between the administrator and the staff so
that all personnel are adequately trained and aware of the expectations of them in
cases of emergency. Training should take place at the beginning of each school year
and should be repeated when a current student is newly diagnosed with diabetes or
when a student with diabetes enrolls in the school. Refresher training is to be done
as needed.
Section 504 of the Rehabilitation Act states that students with disabilities must be
given an equal opportunity to participate in academic, nonacademic, and
extracurricular activities. A student not receiving special education services can still
be entitled to related aids and services under Section 504. Administering insulin or
glucagon, assisting with checking blood glucose tiers, and allowing the student to
eat snacks in school, having a buddy walk down to the office with a student that has
low blood glucose, are a few examples of related aids and services that schools may
have to provide to a student with diabetes. These related aids and services as well
as any needed special education services are commonly written up in a document
called a Section 504 Plan. A child with diabetes may also be covered by IDEA which
provides an eligible student with related nursing services.
Should the nursing assessment reveal that some services the child requires to
remain safely at school cannot be delegated by a nurse and school nursing services
are needed, the school nurse will plan with the school administrator, school team,
and parents and student (if appropriate) how those services will be provided as
mandated by law.
Can schools’ nurses delegate the task of administering insulin and
glucagon?
Delegation in school nursing is a complex process in which the authority to perform
a selected nursing task is transferred to a competent unlicensed individual (UAP) in
a specific situation. The decision to delegate and the supervision of delegation of
nursing tasks in the school setting rest solely with the registered nurse, who makes
the determination to delegate based on nursing assessment and in compliance with
applicable laws and guidance provided by professional nursing associations, National
Guidelines for Nursing Delegation. Any nurse who delegates a task must consider
factors such as the stability of the student’s situation and whether the nursing needs
of the student are changing. School nurses may delegate injectables such as insulin
and glucagon if the school nurse judges the person performing the injection is
capable. There may be special circumstances when those working closely with a
student are appropriate delegates and, in those circumstances, the school nurse
would delegate, train, and supervise that unlicensed staff. It is important to
remember that the nurse must always act in accordance with the policies and
procedures of his/her employer.
Frequently Asked Questions
School Health Services/School Nursing
35
What paperwork must be in place for a student to possess/self-
administer their diabetes medication at school or school sponsored
activities?
Although individual school district forms, policies, and procedures may vary
regarding possession and self-administration of medication in school, the following is
required self- possession of emergency medications:
• Current physician prescription.
• Written treatment plan from the physician including a statement that the pupil
can self-administering the medication under the treatment plan.
• Parent consent.
• A school nurse will determine whether a student who self-administers
medication is responsible to self-carry their medication. The developmental
ability of the student, the need to have ready access to emergency medication
and the safe storage of medication must be considered when making this
decision.
• These documents should be renewed yearly, or as any changes in the
student’s treatment plan are made.
Students with diabetes are generally encouraged and allowed to both possess and
self-administer diabetes medication (insulin and glucagon) to keep blood sugar level
as normal as possible as part of their daily management plan. The student’s
Diabetes Emergency Care Plan completed by the healthcare provider will direct
possession/self-administration and how often services are required in schools to
provide the best care for that student.
What can schools do to assist students with Diabetes?
Diabetes is one of the common chronic diseases. It requires management 24/7.
Keeping glucose (blood sugar) levels in a healthy range is important to maintain
good health. That means careful monitoring of glucose levels for students with
diabetes must occur throughout the school day. Administering insulin by injection or
with an insulin pump to control their blood glucose and minimize complications must
also occur with meals taken at school. The type of help students may need to
manage their diabetes may vary based on their age, how long it has been since
diagnosed and the student’s level of self-care.
To successfully care for students with diabetes follow the recommended guidelines
by the American Diabetes Association Helping Students with Diabetes Succeed: A
guide for School Personnel. Recommendations include:
• Review Federal Laws
• Assemble all healthcare plans
• Assemble a school health team
• Provide staff training
• Provide continuous glucose monitoring
• Recognize and treat hyperglycemia and hypoglycemia
• Administer insulin
• Administer glucagon as needed for hypoglycemia
• Plan for disasters, lockdowns, and emergencies
Frequently Asked Questions
School Health Services/School Nursing
36
• Follow an individualized meal plan
• Plan for special events, field trips and extra-curricular events
• Deal with emotional and social issues
• Understand why self-management is important
What are the requirements to make food substitutions for a
student when school meals are concerned?
If a student has a documented disability or medical issue that restricts their diet, the
school foodservice department MUST make the substitutions as listed by a
licensed medical professional (MD, DO, NP, PA) on a completed medical statement
form MDE Special Dietary Needs. If, however, a request for food substitutions is
made for a student without a documented medical issue, the school foodservice
department MAY make the substitutions listed on the medical statement form
signed by a recognized medical authority. Any substitution of this kind must fully
meet the reimbursable meal pattern.
It is the responsibility of the parent/guardian making the request to submit a
properly filled out and documented medical statement form. Voluntary Guidelines for
Managing Food Allergies in Schools, Early Childhood and Education Programs. (See
page 43).
Return to top
What resources are available for the school nurse to use to support
their students with diabetes?
• American Diabetes Association Diabetes Training Standards for School
Personnel
• Diabetes Care Tasks at School
• NASN Diabetes in Children
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses Section 504 Plan
• Diabetes Medical Management Plan
• JDRF School Advisory Toolkit for Families
• Helping the Student with Diabetes Succeed: A Guide for School Personnel
• Safe at School Training Curriculum: Diabetes Care Tasks at School: What Key
Personnel Need to Know
• Michigan State Board of Education Model Policy on The Management of
Diabetes in The School Setting
• School Nursing Evidence-Based Clinical Practice Guideline: Students with
Type 1 Diabetes
Frequently Asked Questions
School Health Services/School Nursing
37
SEIZURES
Additional Information on Seizures:
Medication Administration
• Requirements, storage, rescue medication, stock epinephrine and other
medications, orders via email, out of state orders, self-carry/self-
possession, field trips, school nurse resources, and actions when parents
do not provide emergency medication.
Health Services Delivery
• Supervision of LPN, students without licensed healthcare provider orders,
orders via email, out-of-state orders, emergency care plans, chronic health
plan accommodations requirements, student safety during school activities,
required food substitutions, staff training, care coordination, Medical
Emergency Response Teams, (MERT).
Field Trips
• What a when child goes on a field trip, out of state filed trips, requirements
for school nurse and prepared medication, and who may accompany
students on field trips.
Return to top
What happens during a seizure?
Seizures can take on many different forms, and seizures affect different people in
different ways, depending on the portion of the brain involved. Anything that the
brain does normally can also occur during a seizure when the brain is activated by
seizure discharges. Some people call this activity “electrical storms” in the brain.
Seizures have a beginning, middle, and end. Not all parts of a seizure may be visible
or easy to separate from each other. Every person with seizures will not have every
stage or symptom described below. The symptoms during a seizure usually are
stereotypic (occur the same way or similar each time), episodic (come and go), and
may be unpredictable.
What is a vagus nerve stimulator (VNS)?
VNS Therapy
is approved by the U.S. Food and Drug Administration (FDA) as an
add-on therapy for adults and children 4 years and older. It is approved to
treat focal or partial seizures that do not respond to seizure medications. This is
called drug-resistant epilepsy or refractory epilepsy.
Frequently Asked Questions
School Health Services/School Nursing
38
What emergency medications are given in school to students with a
seizure disorder?
Three (3) seizure rescue medications are approved by the FDA, Diastat AcuDial
(rectal diazepam), Nayzilam (intranasal midazolam) and Valtoco (intranasal
diazepam). Michigan School Health: Seizure Rescue Medications
The Seizure Emergency Care Plan will define when seizure rescue medication should
be given. The most common guideline for rescue medication is if the seizure last
more than 5 minutes. Other orders may state to give to rescue medication if the
seizure last 2 or 3 minutes or when the seizure begins. These factors must be taken
into consideration when determining the storage of these emergency medications.
Storage placement will determine if the student can receive the seizure medication
in a timely manner.
How are student’s seizure medications stored at school?
The rescue medications for seizures are often controlled substances. The instructions
within the orders for these medications will determine how these medications will be
safely stored. Typically, there is a window of time adequate for the MERT team
response to retrieve the medication from a locked storage. Individualized plans must
be developed if this is not the case.
All controlled-substance 1 medications will be counted and recorded upon receipt
from the parent/guardian. The medication shall be recounted on a regular basis
(monthly or bi-weekly) and this count reconciled with the medication administration
log/record. Control medications must be double locked in a secure area. Emergency
medications should be stored in an area readily accessible to the individual
designated to administer them.
What type of seizures are there?
The type of seizure depends on what part of the brain is involved. Here is a list of
the types of seizures we may see at school:
• Generalized Tonic-Clonic Seizure: (formerly called grand mal), has a return to
full consciousness.
• Generalized Absence Seizure (formerly called petit mal), most common in
children, returns to full consciousness.
• Atonic Seizure: sudden loss of muscle tone that may cause a drop of the head
or fall to the ground, many must wear helmets.
• Tonic Seizure: sudden stiffening of the body, which may cause a fall if
standing, regains consciousness promptly with little or no confusion.
• Myoclonic Seizure: sudden, involuntary, brief, shock-like bodily jerk caused by
contractions of one or more muscles or muscle groups and often occurs in
clusters.
• Focal Impaired Awareness Seizure: (Complex Partial Seizure): usually starts
with blank stare, person is unresponsive, may be confused for several
minutes after the seizure.
Frequently Asked Questions
School Health Services/School Nursing
39
• Focal Aware Seizure (Simple Partial Seizure): person is fully aware during the
seizure, referred to as an aura if it precedes another seizure.
• Focal to Bilateral Tonic-Clonic Seizure: (Secondarily Generalized Seizure):
seizure that begins in one part of the brain and spreads to both sides of the
brain.
What paperwork must be in place for a student to possess/self-
administer seizure medication at school?
Currently, all seizure rescue medications are “controlled substances”. This
medication category is required to be stored in a double locked area and would be
unavailable for a student to self-possess. A word of caution, a student’s safety may
be at risk if allowed to self-carry/self-administered emergency seizure medications.
Return to Top
What can schools do to assist a student with Seizures?
The American Academy of Pediatrics (AAP), Seizure Management in Schools under
Steps for Schools states “For students with frequent seizures, consider having school
nurses provide case management or additional services such as conducting home
visits, assisting with making appointments, connecting families with transportation
assistance, etc”.
Schools can support students with epilepsy by:
• Being knowledgeable about Schools and Seizure Preparedness
• Learning How Schools in Your Community Address Epilepsy
• Creating a Seizure Action Plan
• Educating Classmates about Epilepsy
• Knowing the Rights Children with Epilepsy Have at School
Return to top
What resources are available for a school nurse to use to support
students with seizure disorders?
• Standards of Care for Supporting Students with Seizures in Schools
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
• Supporting Students with Epilepsy/Seizure Disorders Toolkit
• Seizure First Aid Toolkit
• Michigan Epilepsy Foundation
• Managing Children with Epilepsy – School Nurse Guide
• Epilepsy Foundation – Seizure Training for School Nurses
• Michigan School Health: Seizure Rescue Medications
• Schools and Seizure Preparedness
• Children with Epilepsy at School
• Seizure First Aid
• Seizure Action Plan
• Sample 504 Plan Return to TOC
Frequently Asked Questions
School Health Services/School Nursing
40
SICKLE CELL DISEASE
Additional Information on Sickle Cell Disease:
Medication Administration
• Requirements, storage, rescue medication, stock epinephrine and other
medications, orders via email, out of state orders, self-carry/self-
possession, field trips, school nurse resources, and actions when parents
do not provide emergency medication.
Health Services Delivery
• Supervision of LPN, students without licensed healthcare provider orders,
orders via email, out-of-state orders, emergency care plans, chronic health
plan accommodations requirements, student safety during school activities,
required food substitutions, staff training, care coordination, and Medical
Emergency Response Teams, (MERT).
Field Trips
• What a when child goes on a field trip, out of state filed trips, requirements
for school nurse and prepared medication, and who may accompany
students on field trips.
Return to top
What considerations apply to a student with Sickle Cell Disease (SCD)
in school?
Management of sickle cell disease is aimed to avoid pain episodes, relieve
symptoms, and prevent complications.
• The student with SCD may receive both routine and emergency medication.
• Pain Relieving Medications: (acetaminophen, ibuprofen and sometimes
narcotics).
• Each individual living with SCD should have a written pain management plan.
Mild pain can often be successfully treated with non-opioid analgesics. (The
most common opioids are codeine, morphine, and oxycodone).
• Do not apply ice. Check temperature for fever before administering
medication.
• Respiratory: Some individuals with SCD may have routine respiratory
medications as well as rescue medications due to history of Acute Chest
Syndrome and/or asthma. Each individual should have a respiratory
medication plan from their pulmonologist and/or hematologist.
• If symptoms are not controlled with medication, a blood transfusion may be
required.
What can schools do to assist a student with Sickle Cell Disease (SCD)?
School staff have an important role in the academic success of a student with SCD.
The CDC created a booklet Tips for Supporting Students with Sickle Cell Disease to
provide tips for these students and recommend the following for these students:
• Ensure adequate access to water/hydration.
Frequently Asked Questions
School Health Services/School Nursing
41
• Allow frequent bathroom breaks, accommodations during extreme
temperatures and conditions, and accommodations during physical education
and recess activities.
• Take special care of injuries and beware of emotional well-being.
• Maintain open communication with the parent/guardian.
• Be responsive to complaints of pain, (one of the biggest challenges of SCD, be
alert for signs of fever, and watch for signs of stroke).
• Create an individualized care plan for each student with Sickle Cell Disease.
What resources are available for a school nurse to use to support a
student with sickle cell disease?
• Supporting Students with Sickle Cell Disease in School – Standards of Care
Including Training Standards for School Personnel (Project in Progress)
• What is Sickle Cell?
• Management of Sickle Cell Disease in the Educational Setting
• St. Jude’s Research Hospital – Sickle Cell Disease Treatment
• Children’s Hospital of Philadelphia Sickle Cell Center
• CDC Fact Sheets on Sickle Cell Disease
• CDC Tips for Supporting Students with Sickle Cell Disease
• NASN Sickle Cell Disease Care Planning for School
• Handouts and Handbook Sickle Cell Information Center
• Sickle Cell and School: A guide to School Policy and Best Practices
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
Return to TOC
Frequently Asked Questions
School Health Services/School Nursing
42
COMMUNICABLE DISEASE AND INFECTION
CONTROL
What diseases do I need to report?
The presence or suspected presence of all reportable diseases, infections, and
conditions are required to be reported to the appropriate local health department. A
list of reportable diseases can be found at 2023 Reportable Diseases in MI-By
Condition.
How do I make a report?
Please contact your local health department for further information on the
mechanism of reporting for your agency.
Does this violate FERPA?
No, under the following provisions: if the MDHHS has determined that a disease
must be reported within 24 hours, this qualifies as a potential public health
emergency. Therefore, FERPA allows you to disclose that information. Once MDHHS
has the information it is protected by HIPAA. HIPAA legislation states that reporting
of Communicable Diseases to the local or state health department or immunizations
to the Michigan Childhood Immunization Registry are exempt because they are
mandated within the Michigan Public Health Code and are used for surveillance and
prevention of communicable diseases. This is addressed in section §164.512(b) of
the HIPAA regulations.
I have seen several cases of an illness/symptom in the last week but
it is not on the reportable disease list. Should I notify someone?
Yes. Any suspect outbreak, cluster of illness, or unusual occurrence of disease that
may pose a threat to the public's health must be reported. If you are uncertain, feel
free to call your local health department for guidance and assistance with disease
management.
What can we do in my school to help prevent the spread of infectious
disease?
Stress the importance of good old-fashioned hand washing as a first step.
Vigorously rub hands with warm soapy water for at least 20 seconds after wiping
nose/mouth, after using the rest room, after touching objects from the
ground/trash, before eating, etc. If soap and water are not available, an
antimicrobial hand wash with at least 60% alcohol is a good substitute.
• Teach students to cough or sneeze in their elbows rather than in their hands or
into the air.
Frequently Asked Questions
School Health Services/School Nursing
43
• Establish a procedure for cleaning classrooms, lunchrooms, restrooms,
athletic facilities, school buses, etc.
• Ensure that students are immunized appropriately.
What resources available for school nurses to use?
• Managing Communicable Disease in Schools (MDHHS/MDE)
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
• Infectious Disease and Public Health
• Information for Schools and Childcare Providers
IMMUNIZATIONS
What immunizations are required in Michigan for school attendance?
• Michigan 2022 Immunization Requirements for Children Entering Kindergarten
and 7th Grade, or Enrolling in a New School District in Grades 1-12
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
• Vision Screening
Are there immunization exemptions?
There is a new waiver process in place for the nonmedical waiver. The Local Health
Department (LHD) can submit a digital nonmedical waiver through Michigan Care
Improvement Registry (MCIR/SIRS). When a digital nonmedical waiver is submitted,
a paper nonmedical waiver is not required to be provided to the school. The
student’s status will automatically be updated to “waived” in MCIR/SIRS.
If a parent/guardian refuses to let the LHD enter the nonmedical waiver into MCIR,
the parent/guardian will be issued a paper copy of the nonmedical waiver that must
be provided to the school. With the new process, schools will no longer be able to
enter nonmedical waivers into MCIR/SIRS. These students will have to be reported
on the School Aggregate Report Form and will need to be removed from the roster
in MCIR/SIRS.
What do schools/school nurses do if there is a disease outbreak at a
school and there are certain students that were exempted from
immunization against that disease?
Schools must collaborate with their local health departments. If your school has an
outbreak, a separate site will be created in MCIR/SIRS. The local health department,
Frequently Asked Questions
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44
immunization field representative, and epidemiologist would be assigned to this site
for the outbreak. The school staff would upload a CSV (comma-separated values)
file of all students for this specific school. Guidance would be provided by the local
health department on how to proceed regarding the outbreak and provide a list of
students that would need to be excluded. FERPA does not apply if there is an
outbreak in a school.
Should Immunization records and waivers, be stored in the CA-60?
See Record Retention, page 53.
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45
ADDITIONAL SCHOOL HEALTH CONCERNS
ADVOCACY
How do I advocate for the health of students and more school
nurses?
See the Michigan Association of School Nurses Advocacy Toolkit
CBD/MARIJUANA/EPIDIOLEX
Are CBD or Marijuana based medications allowed to be administered
in schools?
Michigan state law specifies that any use of cannabis must take place in private,
such as the user's own residence. It is illegal to use cannabis in a public space. It is
also illegal to carry cannabis in areas frequented by children, such as schools or
school busses. CBD products are not monitored for THC and therefore are not FDA
approved.
Marijuana in Michigan: What You Need to Know
Laws and Model Policies that Guide School Health Service Programs – A Resource for
School Nurses
Is Epidiolex allowed to be administered in schools?
EPIDIOLEX
®
(cannabidiol) is a highly purified cannabidiol (CBD) oral solution
prescription medication with less than 0.1% of tetrahydrocannabinol (THC) approved
by the U.S. Food and Drug Administration (FDA) for treatment of 3 conditions,
Dravet Syndrome, Lennox Gastaut Syndrome (LGS) and Tuberous Sclerosis Complex
(TSC).
In April of 2020, the Drug Enforcement Administration (DEA), announced that
Epidiolex, is no longer considered a controlled substance and therefore, is no longer
subject to the Controlled Substances Act (CSA). In June of 2020, the Michigan
Board of Pharmacy agreed to de-schedule Epidiolex. Public Act 283 of 2016 DOES
NOT apply to the use of Epidiolex when prescribed by an appropriately licensed
provider. Epidiolex is not a rescue drug medication and has not been studied as a
rescue medication. For more information see “Medication Guide”.
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CHILD ABUSE
Who are the mandated reporters of suspected child abuse in schools?
Michigan law requires that certain persons report any case of suspected child abuse
or child neglect to the Michigan Department of Health and Human Services
(MDHHS). The definition of mandated reporter includes all school administrators,
school counselors, school teachers, and school nurses.
Michigan law requires that you must file a report when you have reasonable cause to
suspect abuse or neglect. This is an extremely low legal standard. Elsewhere in this
pamphlet is a description of certain signs of abuse and neglect. However, you must
keep in mind that you are not required to determine whether abuse or neglect has
occurred. MDHHS is responsible for investigating reports of abuse and neglect and
for determining how each case progresses. You must make a report whenever you
suspect that abuse or neglect may have occurred.
What resources are available for the school nurse to use to support
working with child abuse?
• Michigan School Health: Critical Communication
• You are a Mandated Reporter
• Mandated Reporters
• Children’s Protective Services
• Child Protection Law
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
What specific emergency preparedness activities should the school be
concerned with?
School Safety provides information on how to plan and respond to school
emergencies with many resources. In addition, the Federal Emergency Management
Agency (FEMA) believes the school has an instrumental role in developing
comprehensive school emergency management and procedures:
• Identifying potential problems in the school environment.
• Coordinating first aid and CPR training for staff.
• Evaluating first aid and emergency care training and exercises.
Return to TOC
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CHOKING
What is the consensus on adding the De Choker/Life Vac choking
rescue device to our emergency equipment and plan?
At this point, the data is very limited to support efficacy. The data found is low-tier
of evidence with limited high-quality studies. Systemic review and meta-analysis
are almost non-existent. The American Red Cross and American Heart Association
are not promoting the use of these devices and continue to promote the chest
compressions/abdominal thrusts. The CDC neither advising for or against.
DENTAL, HEARING AND VISION SCREENINGS/SCHOOL ENTRY
What dental, hearing and vision screenings are required for Michigan
school attendance?
Sec. 9307 of the Michigan School Code states (1) A parent, guardian, or person in
loco parentis applying to have a child registered for the first time in kindergarten or
first grade in a school in this state shall present to school officials, at the time of
registration or not later than the first day of school, a certificate of hearing and
vision testing or screening or statement of exemption under section 9311. (2)
Before November 1 of each year, the principal or administrator of each school shall
give the state and local health departments a summary of the hearing and vision
reports at the time of school entry of new entering kindergarten and first grade
students. The reports must be made on forms provided or approved by the
department.
Sec. 9312. Records of hearing or vision testing and screening administered and
conducted under this part and of dental oral assessments administered and
conducted under this part must be made and preserved as provided by the
department. The records must be available to health agencies and other persons to
assist in obtaining proper and necessary health, dental, and educational care,
attention, and treatment as permitted by the department. Individual records are
confidential as required by Section 2637 [of the Michigan Public Health Code].
ENVIRONMENTAL HEALTH
What is the school nurse’s role in environmental health?
The school nurse can assess for environmental health hazards, implement, and
coordinate individual health and social interventions, and addresses social
determinants of health based on the National Association of School Nurses
(NASN) Framework for 21
st
Century School Nursing Practice™ (NASN, 2016), to
positively influence children’s environmental health (Campbell & Anderko, 2020).
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What resources are available for the school nurse to use regarding
environmental health issues?
• NASN Environmental Health
• Environmental Health: In the School Setting
• Environmental Health Impacts on Student Health (MASN/NASN membership
required)
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
Are there recommendations regarding service animals/pets in the
classroom?
Under the Americans with Disabilities Act (ADA), public entities and places of public
accommodation such as state and local governments, businesses, and non-profit
organizations cannot discriminate against persons with disabilities in their programs,
services, or activities. Generally, this means that they must allow service animals to
accompany persons with disabilities into areas and locations where the public is
allowed to go.
It is important to consider the health and safety of students before deciding to have
pets/animals in a classroom. Special considerations should be made regarding
students who may have allergies to pets/pet dander.
For additional information, Services Animals in Michigan – Frequently Asked
Questions and the National Association of School Nurses position statement on
Service Animals in Schools, (2019).
Are schools required to provide soap in the student restrooms?
It is recommended that all school facilities have soap as well as running water,
towels, and/or hand dryer available in all restrooms on a campus. A lack of hand
washing facilities/supplies may increase the incidence of communicable diseases
among students and staff, thus increasing absentee rates. Proper and frequent hand
washing is the single most effective method to prevent disease transmission.
EMERGENCY PREPAREDNESS
What is required of schools for emergency preparedness?
Under Sec. 1308b. of the Michigan School Code, a school district, intermediate
school district, or public-school academy shall, in conjunction with at least 1 law
enforcement agency that has jurisdiction over the school district, intermediate
school district, or public-school academy, conduct a review of the emergency
operations plan developed or adopted, including a review of the vulnerability
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assessment or conduct a review of the statewide school safety information policy
described, as applicable.
A school district, intermediate school district, or public-school academy shall develop
an emergency operations plan for each school building operated by the school
district, intermediate school district, or public-school academy with input from the
public. The board of the school district or intermediate school district or the board of
directors of the public-school academy shall adopt the emergency operations plan by
a majority vote of the members serving on the board or board of directors at a
public meeting of the board or board of directors.
The emergency operations plan developed and adopted must include guidelines and
procedures that address at least all the following:
• School violence and attacks.
• Threats of school violence.
• Attacks, bomb threats, fire, and weather-related emergencies.
What is the school nurse’s role in emergency preparedness?
The school nurse is the ideal person to bridge the school and emergency responders.
They understand and quickly communicate with both communities. In addition, the
school nurse includes the Medical Emergency Response Team (MERT) and Triage
into the school’s emergency response. The NASN Position Statement states The Role
of the School During and After a Disaster Position Statement (2011) includes:
• Prevention: work with school administration and community members to
develop and implement the school’s safety program, educate, and train staff.
• Preparation: serve on disaster planning committees and work with parents,
students, teachers, and school administrators to create, evaluate, and revise
emergency action plans.
• Response: facilitate evacuation, provide triage during an emergency,
providing direct, hands-on care to students (including special need students)
and staff, and communicate important health information to school
administration and community members.
• Recovery: school nurses may need to assist students, parents, and
administrators as they heal both physically and mentally. School nurses can
refer children, teachers, and other staff for psychological care (as needed
and/or requested). School nurses can also provide feedback to community
planners, to ensure that improvements to future emergency responses better
address the needs of children, staff, and others.
Return to TOC
What resources are available for the school nurse to use to support
emergency preparedness?
• Approved CPR & First Aid Providers
• HHS Child and Adolescent Health Emergency Planning Toolkit: Guidance for
Addressing the Needs of Children and Youth with Special Health Care Needs
• K-12 Schools: How to Prepare for Emergencies
• NASN Position Statement – Emergency Preparedness
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50
• NASN Disaster Preparedness
• Emergency Checklist for Students with Special Needs
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
• School Safety During an Emergency Crisis: What Parents Need to Know
• OK2Say Michigan Student Safety Program
FIELD TRIPS
What happens when a child goes on a field trip?
Field trips are included in any Free Appropriate Public Education designation. Any
school sponsored field trip must be open to any student regardless of their health
needs. The school is responsible for having trained staff available to support the
student during these events.
It is critical to include collaborative planning for field trips when accommodations are
discussed with school team members to ensure that the school nurse will be able to
fully participate. The accommodations can include provisions that require the
teacher to notify parents and the school nurse in advance of upcoming field trips and
for the teacher, parent/guardian, and school nurse to collaborate in preparing for
the trip. Advance notice allows staff and parents time to investigate the destination,
to identify safety risks, plan for meals and snacks, and ensure that the same or
comparable safety provisions as in school are in place on the field trip.
In addition, the child’s group should be assigned to a school staff member who is
trained in medication administration including emergency medication, and other
health needs that must me net. The emergency medication should always remain
with that child including during transportation to and from the field trip destination.
Parents may want to volunteer to be a chaperone on trips that are more complicated
in terms of safety issues but should never be required to be a chaperone or to be
responsible to provide health support to students who are not their children.
MDE/MDHHS Field Trip form.
What if the field trip is out of state?
Guidance from the License and Regulatory Affairs in Michigan (LARA) states if any
school nurse will be providing medical services outside of the state in which they are
licensed, they will need to check with that state to verify if they have an exception
for a school nurse to not be licensed in their state to provide those services.
Must the school nurse accompany students on a field trip that are
known to have an allergic reaction or have other health needs?
A school nurse who is familiar with the students’ health condition and treatment may
need to accompany a student if the school nurse determines that medical care
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cannot legally or safely be delegated, (School Sponsored Trips-The Role of the
School Nurse). The administration of epi-pens and medication/procedures for other
chronic health conditions can be carried out by adequately trained school personnel,
or even self-administered by the student, if this has been agreed upon and planned
for by the parents/guardians, physician, school administrator, and nurse.
For this reason, school administrators, working with a school nurse, should create
procedures for how emergent situations are handled when a school nurse in not
present. The school nurse plays a key role here in facilitating communication
between the administrator and the staff so that all personnel are adequately trained
and aware of the expectations of them in cases of emergency. If a school does not
have the services of a school nurse, please see “Delegation vs. Training”.
What should the school nurse do regarding preparing medications for
field trips/school sponsored activities?
The Michigan Department of Education developed a Model Medication Policy for
schools. As required by law, the district should have in place a medication policy
that follows the state guidelines, and this policy should be reviewed regularly. The
school district policy should address field trip medication.
A parent/guardian may request from the pharmacy that a single dose of medication
for the field trip be placed in a properly labeled prescription bottle or OTC container
to be given on the school-sponsored trip by school personnel.
The employee assigned the task of administration of medication to the student on
the field trip/ school sponsored event should be trained in medication administration
and will carry the child’s medication in the original container on the field trip/school
sponsored event. A documentation mechanism should be developed as well, to
include in the student's medication administration record.
HEADLICE/PEDICULOSIS
Are no-nit policies or mass screenings recommended for schools?
There is consensus that no-nit policies are inappropriate in a school setting,
according to the American Academy of Pediatrics, National Association of School
Nurses, the CDC, and the MI Department of Health and Human Services. School-
wide screenings and “no-nit” policies are strongly discouraged. Mass screening for
live lice has not been proven to have a significant effect on the incidence of head lice
in a school community over time. Manual removal of nits after treatment with a
pediculicide is not necessary to prevent spread (American Academy of Pediatrics
Pediculosis Clinical Report, 2022). Education of parents in identifying and managing
head lice is the most helpful. School districts ae urged to ensure that children do
not miss class unnecessarily or encounter embarrassment and isolation, especially if
they suffer from repeated head lice infestations. Parents should be encouraged to
check their children’s heads for lice if the child is symptomatic and when close
contacts have head lice.
Frequently Asked Questions
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52
Please refer to Michigan Head Lice Manual, National Association of School Nurses-
Head Lice
Is head lice/pediculosis reportable?
Yes, pediculosis is reportable to your local health department.
MENTAL HEALTH
What is the school nurse’s role in mental health services?
The school nurse serves in a vital role in the school community by promoting
positive mental health outcomes in students through school/community evidence-
based programs and curricula. School nurses work with staff, community health
care professionals, students, and families, in the assessment, identification,
intervention, referral, and follow-up of children in need of behavioral health services.
School nurses may the first to recognize symptoms and connect students/families to
resources.
School nurse services also address access to care, cultural competency, health
education, health equity, outreach, risk reduction, social determinants of health, and
surveillance. The Behavioral Health and Wellness of Students.
What resources are available for the school nurse to use to support
students with mental health issues?
• NASN Mental Health Resources
• MASN Mental Health Consideration Document
• The Behavioral Health and Wellness of Students
• MDE Mental Health Toolkit
• MDE Mental Health
• Motivational Interviewing (MI) for School Nurses – Overview of Steps and
Implementation Tool
• 988 Suicide & Crisis Lifeline
• Child & Adolescent Health Center Program
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses (Rights of Minors)
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RECORD RETENTION
Should immunization records, waivers, hearing, vision screening, and
dental screenings be stored in the CA-60?
Immunization, vision, hearing, and dental screening information are often included
in the CA-60. It is not required, but this practice has been adopted by school office
personnel for convenience to keep all registration information in one place.
Certainly, privacy and security are important considerations when deciding where to
store confidential health records.
When we place health information in the CA-60, there is potential for violating
confidentiality. We may not have the parent’s permission to share personal health
information (PHI) and there may be many eyes on the CA-60 throughout the school
day. If it is possible/practical to keep confidential health records separate from other
records in a secure health file, that is encouraged.
How long do I have to keep records?
All student health records must be retained until the student graduates plus 7 years.
Then they may be destroyed. The General Schedule for Michigan Public Schools was
revised and approved on April 11, 2023, by the Michigan Department of Education,
Department of Technology, Management and Budget – Records Management
Services, Department of Natural Resources - Archives of Michigan, and the State
Administrative Board.
Student Health Records document a student’s health, and health services provided
by a school nurse, or designated school personnel acting in the absence of a school
nurse. They may include, but may not be limited to, immunization records, doctor’s
medical orders, physician instructions, medication administration records, vision and
hearing screening tests, nursing notes, nursing care plans, nursing reports, and
treatment records.
SECTION 504/SPECIAL EDUCATION
What resources are available for the school nurse to use when
supporting with students that require a Section 504 Plan?
• IDEIA and Section 504 Teams - The School Nurse as an Essential Team
Member
• MDE Sample 504 Plan
• Transition Planning for Student with Healthcare Needs
• Family Matters Special Education 504 Plans Fact Sheet (michigan.gov)
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses
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What resources are available for the school nurse to use when
supporting with students that required special education services?
• MASN Special Education Resources for Special Education (comprehensive list)
• HHS Child and Adolescent Health Emergency Planning Toolkit: Guidance for
Addressing the Needs of Children and Youth with Special Health Care Needs
• Individual Transportation Plan (ITP) for Students with Special/Individual
Needs
• Emergency Checklist for Students with Special Needs
• Krieger Institute: Information for School Nurses for the Specialized Health
Needs Collaboration
• The Role of the School Nurse in Special Education Process: Part 1 Student
Identification and Evaluation (MASN/NASN membership required)
• The Role of the School Nurse in Special Education Process: Part 2 Eligibility
Determination and the Individualized Education Program (MASN/NASN
membership required)
• IDEIA and Section 504 Teams - The School Nurse as an Essential Team
Member
• Family Matters
• Transition Planning for Students with Healthcare Needs
• Laws and Model Policies that Guide School Health Service Programs – A
Resource for School Nurses (Federal/State Laws)
What is the school nurse’s role in a Section 504 Plan/Special Education
Individualized Education Plan (IEP)?
As an essential member of the Section 504/ IEP team and the expert in school
health, the school nurse works with other team members to identify, evaluate, and
develop plans for students in need of educational or academic accommodations and
special education services. The school nurse:
• Completes a health assessment.
• Identifies the student’s barriers that impact the student’s ability to learn.
• Determines what accommodations needed to decrease or remove those
barriers.
• Provides a summary evaluation.
• Continues to monitor the student and make any appropriate changes to the
plan as necessary. IDEIA and Section 504 team - The School Nurse as an
Essential Team Member.
Last Updated December 2012
Updated: September, 2023
