Forms can be returned or faxed to your child's school.

For questions, contact:
Pam Jesse, RN
District Nurse
(262) 789-6439
(262) 789-6261 (Fax)

Click on a form below to download. Requires Adobe Acrobat Reader to open.

Program/Service Description:

Health and nursing services support students by managing health related barriers to learning. Direct services are provided to students through the combined efforts of clerical assistants, school secretaries, Red Cross trained volunteers, designated teachers and instructional assistants.

Minor illness or injury will be taken care of by a trained, designated staff member. In case of a serious illness or injury, trained staff will provide basic first aid and use the emergency medical services by calling 911, when necessary.

Student Health Services include medication administration, health care plans, first aid and illness care, emergency care, immunization records, special health care procedures, vision and hearing screening and health education.

Role of Position:

Strengthens and facilitates the education process by modifying or removing health related barriers to learning in individual students and promotes an optimal level of wellness for students and staff.

Coordinate health services through training, delegation and supervision of staff, and act as liaisons between school, home, health care providers and the community.


Specialized Health Care Services, Policy 5142.2


Medical Forms

Asthma Health Care Form
Allergy Health Care Form
Eating and Feeding Evaluation Form
To be completed for children with special dietary needs/food allergies
Authorization for the Administration of Non Prescription Medicine
Authorization for the Administration of Prescription Medicine
Student Emergency Information Form
School Dental Referral Form
Student Health Examination Form
Requested for students entering grades K, 5, 9

Immunization Information

Student Immunization Record
Last Updated 1/15/13
Wisconsin Immunization Registry
Meningitis Information
Meningitis Fact Sheet
Measles Fact Sheet
Measles Letter for Parents

Flu/Virus Information

Enterovirus D68 Fact Sheet
A Guide for Parents - Seasonal & H1N1 Flu
Posted 10/20/09
Stop Germs at Home

Health Information

When to Keep Your Child at Home
Treat Guidelines / Peanut Allergies
Medication Policy

Lice Information

S.C.R.A.T.C.H Slideshow
Fact sheet

School Fax Numbers


Elmwood Elementary
(414) 427-7290
Orchard Lane Elementary
(262) 789-6286
Poplar Creek Elementary
(262) 789-6234
Ronald Reagan Elementary
(262) 789-6205
Eisenhower Middle & High
(262) 789-6313
New Berlin West Middle & High
(262) 789-6442


School District of New Berlin