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Manual For School Health Programs

Chapter 6: Laws, Rules, and Regulations Relating to Schools

Manual For School Health Programs


Chapter 6: Laws, Rules, and Regulations Relating to Schools

Federal

Congress enacted the Education for All Handicapped Children Act (Public Law 94-142), also known as the EHA, in 1975, to support states and localities in protecting the rights of, meeting the individual needs of, and improving the results for infants, toddlers, children, and youth with disabilities and their families. The 1990 reauthorization of the landmark law changed its name to the Individuals with Disabilities Education Act (IDEA). Congress last reauthorized the law in 2004 (U.S. Department of Education, 2023). Before IDEA, many children with disabilities were denied access to public education and learning opportunities and were placed in institutions or separate educational sites. With IDEA, public education systems integrated children with disabilities. With this integration, school districts sometimes experience challenges in providing for students with complex disabilities.

The Family Education Rights and Privacy Act (FERPA) requires all school districts to adopt a policy regarding confidentiality of school records and a process for parent(s)/guardian(s), and students who have reached age 18 to access records as appropriate.

Generally, schools must have written permission from the parent or eligible student to release any information from a student's education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31):

  • School officials with legitimate educational interest.
  • Other schools to which a student is transferring.
  • Specified officials for audit or evaluation purposes.
  • Appropriate parties in connection with financial aid to a student.
  • Organizations conducting certain studies for or on behalf of the school.
  • Accrediting organizations.
  • To comply with a judicial order or lawfully issued subpoena.
  • Appropriate officials in cases of health and safety emergencies.
  • State and local authorities, within a juvenile justice system, pursuant to specific state law. (U.S. Department of Education, 2021)
HIPAA vs FERPA Infographic 2018
(Source: CDC, 2018)

View full infographic here.

The Health Insurance Portability and Accountability Act (HIPAA) guarantees privacy of health information and requires written consent to share health information among certain parties. This usually does not pertain to schools but may impact the school nurse when communicating with health care facilities (see Appendix 6A—HIPAA Compliant Form).

The Americans with Disabilities Act and the Rehabilitation Act of 1973 (Section 504) both allow a school to reject or exclude an employee or student who poses a “direct threat” to the health and safety of others. In addition, it requires schools to make reasonable accommodations for students who have disabilities that interfere with life activities, including learning. These students may require the development of a Section 504 Accommodation Plan. Under this law, public school districts have a duty to provide a free and appropriate public education (FAPE) for students with disabilities. A student with a life-threatening food allergy may qualify as disabled under Section 504. This section of the federal law protects public school students with a disability from discrimination.

The Protection of Pupil Rights Amendment (PPRA) (20 U.S.C. § 1232h, 34 CFR Part 98) provides parents of students, certain rights regarding, among other things, participation in surveys, the collection and use of information for marketing purposes, and certain physical exams. The law requires districts to develop and adopt policies, in consultation with parents, to address the protection of student privacy and parents’ rights under PPRA. In addition, LEAs must directly notify parents of these policies at least annually, at the start of each school year, and within a reasonable period after any substantive change to the policies (U.S. Department of Education, 2020). PPRA directs LEAs to send a notice with an opportunity for opting out of any non-emergency, invasive physical examination or screening that is not necessary to protect the immediate health and safety of a student, with some exceptions, the district requires as a condition of attendance.

Missouri State Laws

Policies and Procedures

Policy vs Procedure

Most school districts post their policies on their websites. Search tabs titled “Board of Education or BOE Policy " usually reveal these. School Nurses must be knowledgeable of and follow school district policies.

The district’s Board of Education writes school policies. Policies set parameters for decision-making but are broad and leave room for flexibility. They show the “why” behind an action. Procedures, on the other hand, explain the how. They are written to implement policy and provide clear guidance on carrying out responsibilities effectively, ensuring consistency and conformity to established standards.

The district’s board of education is responsible for developing and approving general policies. The district advisory council and/or administrative staff are responsible for writing and approving specific (working) administrative procedures and protocols. Employees must know and adhere to district policies and procedures to protect students, the district, and themselves.

To provide context for the policy, policy developers should include a general statement about the school district’s belief regarding the policy. An administrative procedure should clearly state the staff person responsible, what action they should take, and what they should document. The following are a few basic health policies your district may have.

In Missouri, our school districts receive policy guidance from either the Missouri School Boards Association (MSBA) or the Missouri Association of Rural Education (MARE).

MSBA policies are “lettered” while MARE policies are “numbered”. The box below is a list of some of the important health services policie. The links will take you to the MSBA or MARE websites that host sample policies you can view; it is important to know your policies and protocols.

MSBA vs. MARE

This document includes a sample list of school policies for your information. As a school employee, you must be familiar with your district’s policies and procedures. *The following are boilerplate language each district can adopt, modify, or disregard at its own discretion.

School Wellness Policy

Required Policy for Most Schools

“A local school wellness policy (LWP) is a written document that guides a local education agency’s (LEA) effort to establish a school environment that promotes students’ health, wellbeing, and ability to learn.” The Child Nutrition and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Reauthorization Act of 2004 established wellness policy requirements for LEAs participating in the National School Lunch Program and/or School Breakfast Program. The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) further strengthened policy requirements and increased transparency. The responsibility for developing, implementing, and evaluating a wellness policy is placed at the local level, so the LEA can address the unique needs of each school under their jurisdiction. (Missouri Department of Elementary and Secondary Education)

School districts can develop wellness policies to meet the unique needs of each school, but at a minimum must:

  1. Include goals for nutrition promotion and education, physical activity, and other school-based activities that promote students’ wellness. In developing these goals, local educational agencies must review and consider evidence-based strategies.
  2. Include nutrition guidelines for all foods sold on each school campus during the school day that are consistent with federal regulations for school meals and Smart Snacks in School nutrition standards.
  3. Include policies for foods and beverages made available to students (e.g., in classroom parties, classroom snacks parents provide, other foods given as incentives).
  4. Include policies for food and beverage marketing that allow marketing and advertising of only foods and beverages that meet the Smart Snacks in School nutrition standards.
  5. Permit parents, students, representatives of the school food authority, teachers of physical education, school health professionals, the school board, school administrators, and the general public to participate in the development, implementation, and update of the local school wellness policy.
  6. Identify one or more school district or school officials who have the authority and responsibility to ensure each school complies with the policy.
  7. Inform and update the public (including parents, students, and others in the community) about the local school wellness policy annually.
  8. At least once every 3 years, assess school compliance with the local school wellness policy, the extent to which the district’s wellness policy compares to model school wellness policies, and progress made in attaining the goals of the local wellness policy. Once completed, the district should make the results available to the public.

Confidentiality

Recommended Policy

All school district employees and volunteers shall universally adhere to the principles of confidentiality and privacy to protect student health information from unauthorized, illegal, or inappropriate disclosure. Districts shall protect student health information regardless of source (i.e., oral, printed, or electronic means) and type of record, record keeping, or method of storage. These requirements of confidentiality apply to all student information including, but not limited to academic, family, social, economic, and health information. Health services personnel shall be knowledgeable about the district’s implementation of the Family Education Rights and Privacy Act (FERPA) (i.e., who can access health records, under what circumstances, and when they may appropriately disclose information). The table below outlines recommendations for district procedures on confidentiality.

Local district procedures on confidentiality should:

  1. Identify individuals who have access to student health records consistent with the Family Education Rights and Privacy Act (FERPA). This includes staff with a “legitimate educational interest” to fulfill his or her professional responsibilities. Except as FERPA permits, the district may not share information contained in student records, including medical and health information, without informed written consent from the parent(s)/guardian(s).
  2. Identify the individual charged with maintaining student health records; typically the building principal or their designee. Many principals delegate this responsibility to the school nurse; however, the principal must always have access.
  3. Include a procedure for settling disputes regarding access to student health records.
  4. Require district staff to maintain student health records in a secure location, accessible to those with a legitimate educational or medical need to know. Control access to electronic records with user authentication to allow access to the appropriate level of information.
  5. Require parental consent before releasing student health records unless such release is permitted pursuant to FERPA, the Missouri Sunshine Law (Section 610.010, RSMo), or other applicable state or federal law.
  6. Include procedures for protecting student health information that is not contained in student records subject to FERPA, such as student health information staff gather for personal records or communicate orally, such as a substitute for that individual. For example, the district may require staff to only communicate student health information in writing and retain it as a student record or prohibit the discussion of health information in the hallways or other common areas where others could overhear such discussions.
  7. Prohibit or restrict volunteer (non-employee) access to student health records. Have volunteers sign a statement acknowledging their obligation to protect the confidentiality of student records in accordance with the law and school board policy.
  8. Require staff maintain health records in accordance with the Missouri Secretary of State’s Office records retention schedule. (see Recordkeeping).
  9. Outline the district’s plan for training staff on confidentiality.
  10. Include a statement that health personnel are obligated to notify the principal if informed of a condition that could require accommodation under federal law.
  11. Establish guidelines regarding the transmission of health information via social media.

Care of Illness and Injury

Recommended Policy

The school district shall handle injuries and sudden illness occurring at school, on school property, or during school-sponsored events appropriately. This includes providing first aid and notifying parent(s)/guardian(s). The district is not responsible for subsequent treatment or medical expense incurred after the administration of first aid.

Local district procedures should include:

  1. A statement that the district will keep emergency contact information on file for each student. Staff will update the information annually and keep information in a location district personnel can readily access. Include:
    • Who to contact in case of illness or injury, and an alternate(s) if staff cannot reach the contact person
    • Contact’s current contact information,
    • Name of the child’s physician or managed care provider,
    • Hospital preference, and
    • Other significant information such as allergies, religious beliefs, etc., that the parent(s)/guardian(s) determines is appropriate.
  2. A statement that, in case of an accident or sudden illness, the district will give appropriate first aid or treatment, contact emergency medical services (EMS) personnel if appropriate, and contact the parent(s)/guardian(s) or designated contact. Include a description of the procedure to notify administration if EMS personnel are called to the school. The parent/guardian bears responsibility for the cost of EMS services.
  3. A statement that the district keeps the names of persons trained in cardiopulmonary resuscitation and individuals to contact in life-threatening situations available in each classroom and posted in other appropriate locations.
  4. Instructions to staff to file incident reports as soon as possible after witnessing or experiencing an intentional or unintentional injury. Staff completing reports should provide copies of all reports to the building administrator and the nurse.
  5. Procedures staff should follow in the event of illness at school. Health personnel should have written protocols to follow in evaluating students. The evaluation should include a) history of symptoms with notice of signs and symptoms of a communicable disease, and b) presence of an elevated temperature. Personnel should isolate students until a professional nurse or physician or unlicensed assistive personnel (UAP) using written protocols (should specify source of written protocols) assesses the student.
  6. A statement that in case of illness during the school day, the school nurse, in consultation with parent(s)/guardian(s) when available, will determine the appropriate course of action including whether the school should release the child from school. The parent/guardian or specified alternate bears responsibility for transportation and supervision of children released from school.
  7. If the district purchases automated external defibrillators, include an explanation of the district’s plan for training personnel to use the and supervision of trained personnel . If applicable, include how the district will communicate the location of automated external defibrillators and the plan for maintenance of equipment.
  8. Procedures for involving the school nurse in the district response to bioterrorism threats and other emergency preparedness activities.

Child Abuse and Neglect

Recommended Policy

School personnel are in a unique position to help children, families, and the community in dealing with the issue of child abuse and neglect. The school setting enables teachers and nurses to observe students over time and to identify appearance and behavior that is unusual. Reporting the suspicion of abuse and neglect is mandated by Section 210.115, RSMo, (revised 2013), for all specified caretakers of children. School personnel recognize that reporting suspicion is not an accusation, but rather a request that a process for providing help begins.

Local district procedures should include:

  1. A statement that the Board of Education requires staff members to comply with the state child abuse and neglect laws and the mandatory reporting of suspected neglect or abuse.
  2. An explanation of the procedure for reporting. In most cases, the procedure will require staff to report suspicions to a designated individual (usually the principal or nurse) who then becomes responsible for making a report via the Children’s Division Child Abuse and Neglect Hotline Unit (CA/NHU) as law requires.
  3. A statement of a good faith reporter’s immunity from civil or criminal liability.
  4. A statement that no policy or procedure precludes any employee from directly reporting abuse or neglect. However, the school official or employee must notify the building principal or designee immediately after making a report.
  5. A statement that, unless the law otherwise requires, it is not the school official or employee who initiated the report’s responsibility to investigate or prove neglect or abuse.
  6. Identify the name/position of the person(s) the superintendent designates as the school liaison(s) and inform the local Children’s Division (Missouri Department of Social Services) office of this information. The Children’s Division will communicate with the school liaison when they receive a report regarding a child enrolled in the school.
  7. A description of the liaison’s responsibilities including the responsibility to develop protocol in conjunction with the chief investigator of the local division office to ensure the information regarding the status of a child abuse or neglect investigation is shared with appropriate school personnel.
  8. Assurance that all written information the school or school liaison receives is subject to the provision of the Family Rights and Privacy Act (FERPA).
  9. Assurance that each staff member has access to the child abuse and neglect reporting policy.
  10. Provision for training and information necessary to assist staff members in identifying possible incidences of child abuse and neglect, including annual updates regarding any changes in the law.
  11. Procedures for interviewing suspected victims of abuse or neglect at school that is minimally disruptive to the child’s education while still providing the child with needed services.
  12. An explanation of the procedures staff will follow when a member of the school staff is the suspected abuser.
  13. Procedures for providing teachers, students, and parent(s)/guardian(s) with a planned program of personal safety awareness and methods for preventing sexual abuse.

For guidelines for mandated reporters see the Mandated Reporter Guidelines.

Screening and Referral Programs

Recommended Policy

Screening is the use of a procedure to examine a large population to determine the presence of a condition or risk factor to identify those who need further evaluation. Screening programs in schools are designed to examine populations at highest risk, at a time when early intervention has the most benefit. Schools should provide parent notification prior to the event with the opportunity to opt out. See Chapter 4 Screenings for the most appropriate screenings for the school setting. Follow-up of referrals for further evaluation is the best measure of the screening program.

Local district procedures should include:

  1. A definition of screening, including the purpose of screening the targeted populations.
  2. A plan for assessing the district screening needs based on best practice recommendations, resources for screening and referral, and results of previous screening programs.
  3. A calendar coordinated with the overall school calendar that reflects the approximate dates for screenings, re-screenings, and follow-up.
  4. Personnel used in the screening process. To conserve professional time, the school may consider using properly trained lay individuals (volunteers) to perform or assist in screening.
  5. Assurances that the school will advise parent(s)/guardian(s) of any scheduled health screening with the opportunity to exclude their child and provide screening results.
  6. The district’s plan for communicating with students (prescreening health education) about the purpose and process for the screening.
  7. Description of screening follow-up activities including parent notification of results, recommendations for further evaluation, and resources for assistance. Include how staff maintain contact with parent/guardian once they identify a health concern to determine if the parent/guardian acted, the action they took, and how to document referral follow-up in the student’s health record.
  8. Procedures for parent(s) to use to consult with district staff regarding the results of any screening.
  9. A requirement that the school nurse notifies appropriate district staff if a screening reveals the possible need for classroom adaptations, special education services, or other accommodations; and a procedure for communicating the information.
  10. A requirement that the school nurse notifies the special education director if a health screening indicates that a student may need special education services or an accommodation plan.

Special Health Care Needs

Recommended Policy

Pursuant to the Individuals with Disabilities Education Act, the Americans with Disabilities Act and the Rehabilitation Act of 1973, the district will provide health care to allow students with disabilities an equal opportunity to participate in the district’s educational program; and as a related service as is required to allow a child with a disability to benefit from the special educational services the child is receiving. The district’s registered professional nurse(s) is responsible for designing an appropriate, holistic health plan for students with special needs in cooperation with the director of special services and in accordance with the student’s IEP or 504 Accommodation Plan.

Local district procedures should include:

  1. Procedures identifying the school nurse’s duties in the identification of students who may be eligible for special services. These duties include participation in screenings and observations, providing input regarding necessary health services and the level of personnel required to provide those services, and the development of the health care plans, if appropriate.
  2. A description of how the nurse will collaborate in identification of all pertinent medical/health information, including sensory competency and health status assessments prior to a scheduled meeting to discuss the student’s special needs.
  3. Procedures for the nurse to make recommendations for the health care portion of an individualized education program (IEP), if appropriate (special care procedures, physical environment, medication effects, activity limitations, equipment, etc.). For students not served through special education services, but who have significant health needs, the nurse will determine the need for any health care plans.
  4. Procedures for the nurse’s role in the development of a Section 504 accommodation plan, if needed.
  5. Procedures for the nurse to review health-related plans at least annually, evaluate the status of health problems and their possible impact on the educational process, and revise goals, objectives, and plans as needed. The plan should include support for the student to self-manage their health condition in the school setting, as age appropriate.
  6. Description of how the nurse will participate in the implementation of any health care plan, including supervision of the caregiver and education of the student, parent/guardian, and staff regarding the health plan, as indicated.
  7. Procedures for utilizing the expertise of the nurse in consultation with special education services regarding students who may need homebound instruction.

Do Not Resuscitate (DNR) Orders

Recommended Policy

Students with special health care needs of varying severity are enrolled in school with accommodations for their special needs. School staff members will provide first aid or emergency care to students in case of sudden illness and injury, to the level of their expertise. The district will maintain staff trained in appropriate care and utilize emergency medical services as needed. The district may make special accommodations and plans, in consultation with the school district’s legal team, for students presenting a Do Not Resuscitate Order (DNR).

According to RSMo 190.63:

“A patient under eighteen years of age is not authorized to execute an outside the hospital do-not-resuscitate order for himself or herself but may have a do-not-resuscitate order issued on his or her behalf by one parent or legal guardian or by a juvenile or family court under the provisions of section 191.250. Such do-not-resuscitate order shall also function as an outside the hospital do-not-resuscitate order for the purposes of sections 190.600 to 190.621 unless such do-not-resuscitate order authorized under the provisions of section 191.250 states otherwise.”

Local district procedures should include:

  1. Procedures staff should follow when a parent presents a DNR order for their child. If consultation with the parent(s)/guardian(s) and the medical provider provides convincing evidence that they recommend and consider appropriate, a DNR order, the school may incorporate an individually designed medical resuscitation plan into the student’s individual health care plan for life-threatening situations. Plan development should include the school nurse, parents, physicians, teachers, and student, when appropriate. The plan shall not deny all life-sustaining activities but shall describe emergency procedures appropriate for this student. The emergency action plan (EAP) should state the procedure staff should follow in the event of respiratory or cardiac arrest. The parent/guardian is responsible for communicating with emergency medical services (EMS) likely to respond to the event to understand their rules and limitations.
  2. If the student is receiving special education services, the district should convene the IEP committee to review the student’s program and placement to determine appropriateness.
  3. If the parent of a student not receiving special education services presents a DNR order to the nurse, the nurse will immediately contact the building administrator to request a meeting to develop a response.

Head Lice

Recommended Policy (may be part of the student health services policy)

Head lice infestations are common in school settings. Transmission occurs by direct contact with the head of another infested individual. Indirect spread through contact with combs, brushes, or hats is unlikely. Head lice are often diagnosed in schools, but transmission usually occurs at home or in the community. The presence of nits reflects an infestation of weeks to months. Research has shown routine classroom and school-wide screenings are not cost-effective and ineffective in reducing head lice infestations over time. Head lice do not carry disease, and therefore schools should not exclude otherwise healthy students from school attendance because of nits or lice. A "no-nit" or “no lice” policy stating that students who still have nits or lice in their hair cannot return to school is not necessary and not recommended. The American Academy of Pediatrics and National Association of School Nurses discourage such policies and believe a child should not miss or be excluded from school because of head lice (National Association of School Nurses, 2020).

Local district procedures should include:

  1. Description of school and community education regarding diagnosis, treatment, and prevention of head lice. Include information sheets in different languages, and the availability of visual aids for families with limited language skills.
  2. Procedure for notifying parent(s)/guardian(s) of the presence of nits and/or live lice. Schools should not exclude students from school or transportation services. The nurse should instruct parents on how to treat the lice.

Communicable Disease Control

Recommended Policy

School districts share the responsibility for communicable disease control with parent(s)/guardian(s) and community health officials. Schools also share the responsibility for educating staff, parent(s)/guardian(s), and children about the value of immunization, good health practices, and communicable disease control (see Appendix 6B: Policy Guidance on Communicable Diseases).

Immunizations

Recommended Policy

Local district procedures regarding immunizations should:

  1. Explain the requirements for immunization records as a condition for school admission, including an explanation of what the district considers satisfactory evidence of immunization, and applicable exceptions. Include resources for obtaining needed immunizations.
  2. Include a procedure for receiving a medical or religious exemption from the requirements.
  3. Include the procedure for admitting students who have not completed required immunizations but are “in progress” of doing so.
  4. Include an explanation of the federal law regarding the admission of homeless children and the procedure for addressing the immunization needs of these students. Under the McKinney-Vento Homeless Education Assistance Improvements Act of 2001, schools cannot have any policies that “may act as barriers to the enrollment of homeless children.” The law specifically mentions policies pertaining to immunizations.
  5. Include assurance that the district will file all reports regarding immunizations as the law requires.
  6. Explain the steps the district will take when students, who are not otherwise exempted, have not received the proper immunizations. Develop district procedures with the goal of keeping children in school. Exclusion from school should be the action of last resort.
  7. Describe how the district will monitor compliance with immunization requirements on an ongoing basis, including notifying parent(s)/guardian(s) when an immunization will become due.

See Missouri Secretary of State: Code of State Regulations (mo.gov) Immunizations

Infectious Disease Control

Recommended Policy

Local district procedures addressing infectious disease control should:

  1. Provide a written exposure control plan and training regarding the plan, including standard precautions for all district staff on an annual basis.
  2. Require all district personnel to exercise standard precautions to minimize the exposure to infectious diseases resulting from contact with bodily fluids.
  3. Outline the district’s plan, if any, for providing education regarding communicable disease control, including HIV infection, pursuant to Section 191.668, RSMo.
  4. Include a statement that the district will allow students with chronic infectious diseases to attend school in accordance with the law (See Appendix 6B Policy Guidance on Communicable Diseases).
  5. Include a statement that the district will keep all information it receives about a person’s HIV status confidential and only disclose information in accordance with Section 191.656, RSMo.

Administration of Medications in Schools

Recommended Policy

Some students may require medication for chronic or short-term illness during the school day to enable them to remain in school and participate in their education. Unless specifically included in the Individualized Education Program (IEP) of a student receiving special education services or a Section 504 Accommodation Plan, the school district is not obligated to administer medications to students. The superintendent, in collaboration with the district’s school nurses or public health nurses, will establish procedures for administration of all medications pursuant to state and federal laws.

Administration of medication is a nursing activity that a registered professional nurse or licensed practical nurse must perform. A registered professional nurse may delegate the administration of medications to unlicensed assistive personnel provided the delegating nurse trains and supervises the staff member. Nurses must use reasonable and prudent judgment to determine whether to administer medications at school while working in collaboration with parent(s)/guardian(s) and school administration. To protect the health and safety of students, the nurse will clarify, when necessary, any medication order. The district should not administer the first dose of any new medication. The school nurse should not, without clarification from the prescriber, administer any medication if the dosage exceeds the manufacturers’ recommendations.

The district may encourage parents to discuss timing of medication administration with the prescribers to determine appropriateness of the student taking the medication outside of school hours whenever possible. A health professional, licensed to prescribe by a state regulatory body, may recommend that a student with a chronic health condition assume responsibility for their own medication as part of learning self-care (e.g., inhalers used for asthma). Districts may allow self-administration of medication if the student meets certain conditions.

Local district procedures should include:

  1. Instructions for providing the school district with standing orders, annually, at the beginning of each school year regarding the administration of medications in emergency situations such as a severe allergic reaction or anaphylaxis. The standing order must include the protocol to follow and who may administer the medication. A registered nurse will train designated personnel in the proper administration of the medication. Parent(s)/guardian(s) of students with known severe allergic reactions must supply the medication, which the nurse will store in a secure location with the standing order.
  2. Procedures staff will follow when a student requires administration of prescription medication at school, including obtaining a physician order. The school nurse is responsible for verifying the physician order, and documenting information regarding the prescription in the student’s health record.
  3. A requirement that staff administer all medications, prescribed and OTC, only upon written request from a parent/guardian.
  4. Procedures for allowing privacy for students receiving medication.
  5. A statement addressing receipt and administration of medications the US Food and Drug Administration (FDA) does not regulate, including herbal or homeopathic preparations, essential oils, cannabidiol (CBD) oil, and medical marijuana.
  6. A statement that the district will not knowingly administer prescription or OTC medications in amounts exceeding the recommended daily dosage listed in the Physician’s Desk Reference (PDR) or other similarly recognized text.
  7. Assurance that the district will administer medication in accordance with the student’s Individualized Education Program (IEP) or Section 504 Accommodation plan, if applicable.
  8. An explanation of the responsibilities of all school personnel in the administration of medications consistent with district policy. Include an explanation of the procedures for training unlicensed assistive personnel (UAP) in the administration of medications, outlining specific procedures and limitations. The nurse is responsible for determining what medications UAPs can safely administer. The nurse should base their decision about delegation following the state nurse practice act and considering on the student’s health status and medication to be administered.
  9. An explanation of the district’s procedures for permitting students with potentially life-threatening respiratory illnesses to self-administer medications such as a metered-dose inhaler. All such procedures must reflect the requirements of Section 167.627, RSMo and include:
    • Written authorization from the parent(s)/guardian(s)
    • A medical history of the illness
    • A plan for addressing emergency situations (Asthma Action Plan/Emergency Action Plan)
    • Written certification from a physician attesting to the student’s need for, and ability to self-administer the medication
    • A statement from the district that the district assumes no liability because of injury arising from self-administration
    • A requirement that the district renew authorization annually
    • A description of the nurse’s role in assuring safe self-administration, including observation of student’s techniques and adherence to prescription
  10. A procedure for documenting administration of medications, both routine and as needed. This information should be documented on an individual medication record that includes the student’s name, prescriber, pharmacy, prescription number, drug, dose, date, time, and name or initials of persons administering the medication. The record should provide space for the full signature of the individuals administering the medication. Individual medication records may be kept in a “medication notebook,” then filed in the student’s individual health record when completed, at the end of the year, or when the student transfers or withdraws from school. All documentation shall be completed in ink. Many districts now have electronic student medication administration programs. All the necessary student medication information should be part of the program to ensure quality controls.
  11. Procedures for collection, storage, and delivery of medications including a statement about parent/guardian delivering all medication to the building principal or designee in a properly labeled container from the pharmacy or in manufacturer’s packaging.
  12. Procedures for governing access to medications. These procedures must be restrictive enough to protect medications from improper distribution, but flexible enough so that medications can be accessed when needed.
  13. Procedures for medication error reporting, evaluation of the cause of the error, and provision of additional education and coaching to the individual involved in the medication error.
  14. (If applicable). Notice that schools in the district are equipped with epinephrine premeasured auto-injection devices that can be administered in the event of severe allergic reaction causing anaphylaxis. This notice should include a list of personnel trained in the proper administration of this drug. Epinephrine will only be administered in accordance with written protocols provided by the prescriber (167.630 RSMo).
  15. (If applicable). Notice that schools in the district are equipped with asthma-related rescue medications that can be administered to any student the school nurse or trained employee believes is having a life-threatening asthma episode based on the training in recognizing an acute asthma episode (167.635 RSMo).

Handling, Storage and Disposal of Medications

Local district procedures should include:

  1. The school district must provide secure, locked storage for all medications to prevent diversion, misuse, or ingestion by another individual. The person responsible for administering Schedule II controlled substances, (e.g., Ritalin) should inventory them upon receipt, and daily. Maintain the record of the drug in a log, or on the student’s medication record. Any count discrepancies should be reported to the school nurse to enable further investigation. Schools should provide double-locked storage for controlled substances, (i.e., a locked box in a locked cabinet or room). The Missouri Bureau of Narcotics and Dangerous Drugs (BNDD) may be contacted at 573-751-6321 as a resource for assistance regarding record keeping, storage, disposal, etc. of controlled substances.
  2. Routinely checking expiration dates on any medication.
  3. Access to stored medications should be limited to the building principal and persons authorized to administer medications. Students who are self-medicating should not have access to other student’s medications. Access to keys should be restricted to the extent possible.
  4. Written procedure for administration of medication during field trips, including delegation, proper labeling, storage of single dose, and method of documenting administration.
  5. A parent/guardian may retrieve their student’s medication from the school at any time.
  6. When possible, schools should return all unused, discontinued, or outdated medication to the parent/guardian, and document the return. With parent/guardian consent, the school nurse may destroy medications if witnessed by another individual and appropriately documented. All medications should be returned/destroyed at the end of the school year.

Role of the School Nurse in Medication Administration

The administration of medications in schools, including over the counter (OTC) medications, is a nursing activity that must be under the control of a registered professional nurse and/or licensed practical nurse. A registered nurse may delegate, train, and supervise the administration of medication by unlicensed assistive personnel who are qualified by education, knowledge, and skill to administer medication. (See Medication Administration in Missouri Schools, Guidelines for Training School Personnel, DHSS, 2020).

It is the registered professional nurse’s responsibility to:

  1. Document the training, education, competency verification, and supervision of unlicensed personnel who are delegated medication administration. A registered nurse may delegate the training of unlicensed personnel to licensed practical nurses who have demonstrated the competency to provide such training. The nurse must periodically monitor medication administration procedures of those trained.
  2. Provide product information, safe dosage limits, side effects, drug interactions, adverse reactions, emergency procedures, and other pertinent drug information as indicated.
  3. Ensure medications originate from an order from an authorized prescriber and are appropriate, labeled, administered as prescribed, and documented appropriately.
  4. Provide for safe, appropriate storage of medication.
  5. Monitor the use of OTC medications and discourage the use of medication that might mask health problems or send the wrong message to students regarding drug use.
  6. Communicate to the parent/guardian and/or authorized prescriber the effect of the medication on the student’s performance and behavior and notify them of frequent requests for medication prescribed “as needed.”
  7. Establish a procedure to document any situations where the medication is not given as prescribed, (i.e., refusal, vomiting, spilled or lost, etc.).
  8. Establish a written procedure for dealing with questionable medication orders/requests, including herbal preparations and OTC medications, that includes notifying the parent/guardian about refusal to give medication due to a concern for the student’s safety. The nurse has a right to refuse to administer any medication they believe is not in the best interest of the student, due to dosage, side effects, or other concerns. Board-approved policies should include a statement about nurse refusal. This situation may require the development of a 504 Accommodation Plan if the parent(s)/guardian(s) requests the school to still administer the medication.

Resources

Table 12. Resources for School Health Programs

Resources for School Health Programs
Missouri Department of Health and Senior Services. (2020). Medication Administration in Missouri Schools: Guidelines for Training School Personnel. [BROKEN LINK]
Missouri Department of Health and Senior Services. (2020). Emergency Guidelines for Schools and Childcare. [BROKEN LINK]
Missouri Department of Social Services (2020). Guidelines for Mandated Reporters of Child Abuse and Neglect.
Smoke Free Schools [NEEDS LINK]
U.S. Department of Health and Human Services & U.S. Department of Education. (2020). Joint Guidance on the Application of FERPA and HIAA to Student Health Records.
U.S. Department of Education. (2008). Joint Guidance on the Application of FERPA and HIPPA to Student Health.
Poison Help: 1-800-222-1222
Poison Help: 1-800-222-1222

References

Authorization For Disclosure

Authorization For Disclosure Of Consumer Medical/Health Information

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Appendix 6B: Policy Guidance on Communicable Diseases

The continuing expansion of knowledge about communicable diseases and expanding statutory and case law on the rights of individuals who may have a communicable disease make it imperative that local boards of education routinely review their policies and procedures for dealing with communicable diseases to make sure they are both legal and effective.

The State Board of Education periodically reviews and updates its policy guidance on communicable diseases and distributes the revised document to public schools. They last revised the policy guidance in 2011. Throughout, the document references the Missouri Department of Health and Senior Services’ Infection Control Procedures for Schools. The State Board of Education recommends that all local boards of education review their policies and procedures and revise as necessary.

Communicable Disease

Student Purpose

The school board recognizes its responsibility to protect the health of students and employees from the risks infectious diseases pose. The board also has the responsibility to uphold the rights of affected individuals to privacy and confidentiality, to attend school, and to be treated in a nondiscriminatory manner.

Immunization

Students cannot enroll and/or attend school unless immunized as Missouri law requires.

Standard Precautions

The district requires all staff to routinely observe standard precautions to prevent exposure to disease-causing organisms, and the district shall provide necessary equipment/supplies to implement standard precautions.

Categories of Potential Risk

Schools should manage students with infectious diseases that may spread in school and/or athletic settings (i.e., chicken pox, influenza, and conjunctivitis) as specified in: a) the most current edition of the Missouri Department of Health and Senior Services Prevention and Control of Communicable Diseases: A Guide for School Administrators, Nurses, Teachers, and Day Care Operators, b) documents referenced in 19 CSR 20-20.030, and c) in accordance with any specific guidelines/recommendations or requirements the county or city health department promulgates.

A student infected with a blood-borne pathogen such as hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV) poses no risk of transmission through casual contact to other persons in a school setting. Schools should allow students infected with these viruses to attend school without any restrictions, which are based solely on the infection. The district cannot require any medical evaluation or tests for such diseases.

Exceptional Situations: There are specific types of behaviors (e.g., biting or scratching) or conditions (e.g., frequent bleeding episodes or un-coverable, oozing skin lesions) which could potentially be associated with transmission of both blood-borne and non-blood-borne pathogens. Schools should not allow any student, regardless of whether he or she is known to be infected with such pathogens, to attend school unless these behaviors or conditions are either absent or appropriately controlled to avoid unnecessary exposure. In these exceptional instances, the student may need an alternative educational setting. In certain instances, a designated school administrator may want to convene a review committee with a limited of persons including: 1) parent(s)/guardian(s), 2) medical personnel (student’s physician, the school nurse), 3) building administrator, and 4) superintendent and/or designee. The school may consult with and/or include local health department officials as members of the review team. If the student is identified as having a disability, the school should work through the Individualized Education Program (IEP) process to change placement. In the case of a student who is disabled but not identified under the Individuals with Disabilities Education Act (IDEA), the school should conduct a multidisciplinary team meeting to change of placement.

School districts should establish specific mechanisms to ensure they consistently do the following:

  1. Report all episodes of biting and all children who exhibit repeated instances of significant aggressive behavior to the designated school administrator.
  2. Inform the school nurse, and the designated school administrator when appropriate, of any child having recurrent episodes of bleeding or un-coverable, oozing skin lesions.
  3. Immediately inform the school nurse, and the designated school administrator when appropriate, of any child with an illness characterized by a rash.
  4. Immediately inform the school nurse, and designated school administrator when appropriate, of any instance with significant potential for disease transmission.
Confidentiality

The superintendent or designee shall ensure the district observes students’ confidentiality rights as the law requires. Missouri law, Section 191.689 RSMo,1994 states the following individuals could be informed of the identity of a student with HIV infection on a “need to know” basis. They are:

  1. Individuals the school district designates to determine the fitness of an individual to attend school (see recommended review committee membership listed above); and
  2. Individuals who have a reasonable need to know to provide proper health care.

Examples of people who need to know are the school nurse, review team members, and the IEP team if applicable. Districts should ensure staff store medical records securely. Breach of confidentiality may result in disciplinary action, a civil suit, and/or violation of the Federal Family Rights and Privacy Act (FERPA).

Education – Student

The district should provide all students with age-appropriate education about the prevention and control of communicable diseases, to include the use of standard precautions. Districts should incorporate instruction within a comprehensive school health curriculum in grades K-12.

Reporting and Disease Outbreak Control

The District shall implement reporting and disease outbreak control measures as state and local laws, Department of Health and Senior Services’ rules governing the control of communicable diseases dangerous to public health, and any county or city health department promulgated rules require.

Notification

Superintendents who supply a copy of a board-approved policy that contains provisions substantially like this guideline to the Department of Health and Senior Services (DHSS) shall be entitled to confidential notice of the identity of any district child reported to the department as HIV-infected and known to be enrolled in the district – whether in a public or private school (DHSS cannot comply with this provision.) The parent(s)/guardian(s) are also required to provide such notice to the superintendent.

Review

Districts should periodically review their policies and procedures and make revisions when necessary.

Approved:

Legal references:
Sections 167.191, 191.650-.730 RSMo
Americans with Disabilities Act (42 U.S.C. 12101 et seq.)
PL 94-142 Individuals with Disabilities Education Act of 1973 (20 U.S.C. 1400 et seq.)
PL 92-112, Section 504 of the Rehabilitation Act of 1973
19 CSR 20-20.010 through 20.20.060 and 20.28.010

Communicable Disease – Employee

Purpose

The school board recognizes its responsibility to protect the health of students and employees from the risks infectious diseases pose. The board also has the responsibility to uphold the rights of affected individuals to privacy and confidentiality, to continue their employment, and to be treated in a nondiscriminatory manner.

Standard Precautions

The district requires all staff to routinely observe standard (universal) precautions to prevent exposure to disease- causing organisms, and the district shall provide necessary equipment/supplies to implement universal precautions.

Categories of Potential Risk

Employees with infectious diseases that can be transmissible in school and/or athletic settings (such as, but not limited to, chicken pox, influenza, and conjunctivitis) should be managed as specified in: a) the most current edition of the Missouri Department of Health document entitled: Prevention and Control of Communicable Diseases: A Guide for School Administrators, Nurses, Teachers, and Day Care Operators and b) the documents referenced in 19 CSR 20-20.030 and c) in accordance with any specific guidelines/ recommendations or requirements promulgated by the local county or city health department. A medical release may be required of the employee in certain circumstances.

An employee infected with a blood-borne pathogen such as hepatitis B virus (HV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV) poses no risk of transmission through casual contact to other persons in a school setting. Employees infected with one of these viruses shall be allowed to continue work without any restrictions, which are based solely on the infection.

Exceptional Situations: There are certain specific conditions (for example, frequent bleeding episodes or un-coverable, oozing skin lesions) which could potentially be associated with transmission of both blood-borne and non-blood-borne pathogens. No employee, regardless of whether he or she is known to be infected with such pathogens, should be allowed to continue work unless these conditions are either absent or appropriately controlled in a way that avoids unnecessary exposure.

Specific mechanisms should be in place to ensure the following are consistently done:

  1. The school nurse, and the designated school administrator when appropriate, should be informed of any staff member who has recurrent episodes of bleeding or who has uncoverable, oozing skin lesions.
  2. The school nurse, and the designated school administrator when appropriate, should be promptly informed of any employee with an illness characterized by a rash.
  3. The school nurse, and designated school administrator when appropriate, should be informed promptly of any instance in which the significant potential for disease transmission occurs.
Confidentiality

The superintendent or designee shall ensure the employee’s confidentiality rights are strictly observed in accordance with law. Security of medical records shall be maintained. Breach of confidentiality may result in disciplinary action, and/or a civil suit.

Training – Employee

All employees should receive training annually on universal precautions and the Communicable Disease Policy.

Testing – Employee

Requiring medical evaluations or tests of employees will not normally be authorized under the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act. Schools may require post-offer, pre-employment, or annual physical examinations if the exam is job-related and if conducted on all employees or applicants for similar positions. Requiring medical evaluations or tests for infection with blood-borne pathogens is not allowed by law.

Reasonable Accommodations

Districts should develop procedures to respond to employee requests for reasonable accommodations when an employee has a disability as defined by Section 504 and/or the ADA.

Reporting and Disease Outbreak Control

Reporting and disease outbreak control measures will be implemented in accordance with state and local laws and Department of Health and Senior Services’ rules governing the control of communicable diseases dangerous to public health, and any applicable rules promulgated by the appropriate county or city health department.

Review

Districts should periodically review their policies and procedures and make revisions when necessary.

Approved:

Legal references:
Sections 167.191, 191.650-.730 RSMo
Americans with Disabilities Act (42 U.S.C. 12101 et seq.)
PL 94-142 Individuals with Disabilities Education Act of 1973 (20 U.S.C. 1400 et seq.)
PL 92-112 Section 504 of the Rehabilitation Act of 1973
19 CSR 20-20.010 through 20.20.060 and 20.28.010

Resources (for appendix):

This project is/was funded in part by the Missouri Department of Health and Senior Services Title V Maternal Child Health Services Block Grant and is/was supported by the Health Resources Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant #B04MC47428, Maternal and Child Health Services for $12,834,718, of which $0 is from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.

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