Select date
Medication Administration FFAC (local)

Principal designee for medication administration form completed and filed in Medication binder

Permission forms from parent/MD completed and filed in Medication binder

Medications organized and stored according to CFISD policy

Epinephrine auto-injectors stored in unlocked cabinet marked "Emergency Medications"

Permission for self-administration of medication completed and filed in Medication binder

Administration of medication is documented daily in electronic medical record (EMR)

Office Visit Documentation

Office visits are documented daily in EMR

Immunization Documentation

Immunization compliance report is up to date (as medically possible)

Immunization exemption certificates and MD letters are filed in Exemption binder and documented in EMR

Documented parent/guardian notification of immunization requirements

Documented notice to campus administration concerning immunization non-compliance


Vision and hearing screening completed 120 days from student enrollment

Spinal and Acanthosis Nigricans screening completed by Spring break

Screening results documented in EMR

Documented monthly biological calibration of audiometer

Demonstrated knowledge of community assistance for vision exams

Clinic Management

Clinic is orderly and free of clutter

Supplies are easily accessible

Otoscope, pulse ox., thermometer, and sphygmometer are in working order

Substitute Notebook

Organized according to CFISD guidelines found in health services handbook

Updated with current campus specific information

Current telephone lists with nearest campus RN phone numbers included

Current campus Alert & Disability roster included

Special Services

Current orders (updated annually) for special procedures in appropriate binder

Current IHPs for identified students

Documented training for delegated procedures

Documented supervision of delegated procedures

Principal UDCA delegation form signed and filed in Diabetes binder

Documented UDCA training filed in Diabetes binder

Emergency Preparedness

Evacuation plan in place

Emergency trauma bag properly stocked and easily accessible

Rolling cart to evacuate medications is easily accessible

AED checklists current (inspected monthly)

Documented evacuation training on file for 2 story campuses

Audit Results

Is follow up audit necessary?

When will follow up audit take place?

Auditor's Signature

Additional Remarks

Campus Registered Nurse Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.