NAME OF STUDENT:

Referral Slip GRADE & SECTION:

NAME OF TEACHER:
TIME LEFT THE CLASS: DATE:
REASON(S) FOR REFERRAL:
DIFFICULTY OF BREATHING EYE INJURY/ IRRITATION PAIN
COLDS SYMPTOMS/ COUGH FEVER RASH
CRAMPS HEAD INJURY SORE THROAT
CUT/ SCRAPE HEADACHE STOMACHACHE
DENTAL INSECT BITE VOMITTING
EARACHE NOSE BLEED OTHERS:
NURSE'S REPORT AND ACTION
FIRST AID RETURN TO CLASS REMARKS:
ICE APPLIED TO GO HOME _________________________
MEDICATION GIVEN TIME PARENT NOTIFIED: _________________________
REST/ OBSERVATION UNABLE TO CONTACT PARENT _________________________
TEMPERATURE TIME TAKEN HOME: _________________________
WARM COMPRESS REFERRAL TO:______________ _________________________
NURSE'S SIGNATURE: __________________________
NAME OF STUDENT:

Referral Slip
GRADE & SECTION:
NAME OF TEACHER:
TIME LEFT THE CLASS: DATE:
REASON(S) FOR REFERRAL:
DIFFICULTY OF BREATHING EYE INJURY/ IRRITATION PAIN
COLDS SYMPTOMS/ COUGH FEVER RASH
CRAMPS HEAD INJURY SORE THROAT
CUT/ SCRAPE HEADACHE STOMACHACHE
DENTAL INSECT BITE VOMITTING
EARACHE NOSE BLEED OTHERS:
NURSE'S REPORT AND ACTION
FIRST AID RETURN TO CLASS REMARKS:
ICE APPLIED TO GO HOME _________________________
MEDICATION GIVEN TIME PARENT NOTIFIED: _________________________
REST/ OBSERVATION UNABLE TO CONTACT PARENT _________________________
TEMPERATURE TIME TAKEN HOME: _________________________
WARM COMPRESS REFERRAL TO:______________ _________________________
NURSE'S SIGNATURE: __________________________
NAME OF STUDENT:

Referral Slip
GRADE & SECTION:
NAME OF TEACHER:
TIME LEFT THE CLASS: DATE:
REASON(S) FOR REFERRAL:
DIFFICULTY OF BREATHING EYE INJURY/ IRRITATION PAIN
COLDS SYMPTOMS/ COUGH FEVER RASH
CRAMPS HEAD INJURY SORE THROAT
CUT/ SCRAPE HEADACHE STOMACHACHE
DENTAL INSECT BITE VOMITTING
EARACHE NOSE BLEED OTHERS:
NURSE'S REPORT AND ACTION
FIRST AID RETURN TO CLASS REMARKS:
ICE APPLIED TO GO HOME _________________________
MEDICATION GIVEN TIME PARENT NOTIFIED: _________________________
REST/ OBSERVATION UNABLE TO CONTACT PARENT _________________________
TEMPERATURE TIME TAKEN HOME: _________________________
WARM COMPRESS REFERRAL TO:______________ _________________________
NURSE'S SIGNATURE: __________________________