Health Office and Forms

Important COVID-19 Updates


Symptom checks for students and staff members are a crucial part of keeping our school communities - and our entire community - safe and healthy amid the pandemic. We ask that all students and families conduct self-checks for symptoms before you leave for school or the bus stop each day.

Before having your student enter a school building, please consider these three important self-screening questions. If you answer yes to any of the following questions, please keep your student home and consult with your family physician. 

  1. Has your student had close contact (within 6 feet for at least 15 minutes) with or without a mask in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider advised the student to quarantine?

  2. Does your student have any symptoms related to COVID-19? Symptoms include: fever of 100.4ºF or higher, chills, cough, shortness of breath or difficulty breathing, fatigue, headache, new loss of taste or smell, sore threat, new or worsened nasal congestion, nausea or vomiting, and diarrhea.

  3. Has your student been diagnosed with or tested positive for COVID-19 in the last 10 days?

Please contact your health office if your student is experiencing symptoms, receives a positive test or has been exposed to COVID-19.  When reporting any absence to your school attendance office, please identify whether the absence is COVID-19 related.


Free COVID-19 rapid test kits are available for pick-up only from our school health offices for any family who wishes to test their child at home due to symptoms or quarantine. You can reach out to your school health office or our COVID nurse coordinator with your student’s test results and with questions about the kits.


Governor DeWine's Statement on Masking for Schools (May 15, 2021) — The Ohio Department of Education issued the following bulletin from Governor Mike DeWine: "Thank you for your hard work this year to provide safe and healthy in-person educational opportunities to Ohio’s students. As you may have seen, the Centers for Disease Control recently revised their recommendations around mask guidance for individuals who are fully vaccinated. While Ohio will be amending its health orders to comply with this new CDC guidance, in order to maintain consistency and model safe behavior for Ohio’s students, these changes do not affect the existing order requiring the use of facial coverings and other health protocols in our schools. With limited numbers of students vaccinated, it is important that we continue these safety measures through the end of the current school year. I appreciate the efforts that you have undertaken locally to protect students and I look forward to continuing to work together for Ohio’s kids."

Franklin County Public Health COVID-19 School Guidance (updated April 5, 2021) — This document serves as a comprehensive guidance document for schools in Franklin County, and it includes updated quarantine guidance for school settings.

Ohio Department of Health Addendum on Quarantine Guidance for Sports and Extracurricular Activities (March 15, 2021) — This document updates quarantine guidance for students regarding  athletics and extracurricular activities.

Franklin County Public Health COVID-19 School Guidance on Positive Cases, Close Contacts and Quarantines (updated February 12, 2021)

Child In-Person Participation Algorithm (updated January 13, 2021) — This document offers guidance on when students should stay home from school and when they may return to school based on the symptoms they have.


Starting March 10, 2021, the Ohio Department of Health will no longer issue a travel advisory for those entering Ohio after traveling to states reporting positive testing rates of 15% or higher. Instead, ODH is revising its travel guidance to encourage Ohioans to carefully review Centers for Disease Control and Prevention (CDC) guidance when considering travel:

Required Forms for Students

Immunization Information

Immunization Report — If you did not complete the immunization report for your student through the online registration system, please complete this form and submit it to your school, or submit an immunization report provided by your physician's office. 
Per Ohio law, new students (kindergartners and students new to the district) are required to have documentation of the state required immunizations on file at their school. Please be sure to submit the your child's immunization record to your school nurse as soon as possible. The state of Ohio allows a 14-day period after entrance to school to submit the immunizations. 
For the immunization requirements for students by grade level, please see: 
For the 2020-2021 school year: 
2020-2021 Immunization Information for Enrollment - updated August 4, 2020 (.rtf) 
For questions about immunizations, or if your child needs additional immunizations, first contact your child's primary care provider. If you need to connect with a vaccine clinic, please visit these webpages for additional details and contact information:

Physician's Report (For New Students only)

Physician's Report —  It is recommended that you complete and submit this form only for the first year that your child is enrolled in Upper Arlington Schools 

Additional Forms

New paperwork is required for each school year.  Please turn in paperwork and emergency medication to your school office or health office by the first day of school. Thank you for your help and cooperation in getting each school year off to a great start!
Please access the collection of forms for various health needs by clicking their name below.

Prescribed Medication Form

This form is to be completed for any prescribed medication that is to be given during school hours.  Parents/guardians read and complete the top portion. Your health-care provider completes the bottom portion. Click the above link above to access a printable copy of this form.  

Life Threatening Food Allergy Forms

Please complete both sides of the Life-Threatening Allergy Action Plan.  This plan needs to be completed for each school year and does require a physician signature.  Please check to see that your child's medication has not expired before turning it in to the health office. Expired medications cannot be sent on field trips or administered in the school setting. You may click on the link above for a printable copy of this form.
This form should accompany the action plan for any prescribed medication that is part of the plan. For example, epinephrine or a prescribed dose of an antihistamine. Parents/guardians read and complete the top portion.  Your health-care provider completes the bottom portion. Click the above link above to access a printable copy of this form. 
Complete this form once upon entrance to the school district or anytime there are significant changes. Click the above link for a printable copy of this form. 
Authorization for Student Possession of and Use of an Epinephrine Autoinjector (PDF)
Please complete this form if your student will carry and self-administer an epinephrine autoinjector. Recommended for middle school and high school students only.

Asthma Forms

Parents/guardians, please fill out the Asthma History Form and complete the Asthma Care Forms and prescription authorization in conjunction with your child's primary care provider. These forms tell us about your student's asthma history, triggers, recent hospitalizations, and medications, and a new set will need completed for each school year. Please click the link underlined above for a printable copy of the Asthma Care Forms. 
Authorization for Student Possession and Use of Asthma Inhaler (PDF)
Parents/guardians, please complete this form if your student will carry and self-administer an asthma inhaler. Recommended for middle school and high school students only.

Seizure Plan Forms

Parents/guardians, please complete this form if your child has a seizure action plan.  A physician signature is required as well as a parent/guardian signature on the second page.
Text-only version: Seizure Action Plan Form (.rtf) 
This form is to be completed for any prescribed medication that is to be given during school hours.  Parents/guardians read and complete the top portion. Your health-care provider completes the bottom portion. Click the above link above to access a printable copy of this form.  

Diabetes Care Plan

This is a sample of a diabetes care plan.  Your healthcare provider may have their own diabetes care plan completed for your child. Click the underlined link above to download a copy if desired.

If your student has been prescribed emergency glucagon, please know that our school nurses train the teachers each year how to administer this life-saving medication.  Your child's glucagon will be kept in the health clinic and will follow them on all field trips.
Text-only version: Diabetes Care Plan (.rtf) 
If your student has been prescribed emergency glucagon, please have your physician complete the prescribed medication authorization form for glucagon.  This form does require both physician and parent/guardian signatures.

COVID Coordinator

Gina Rancitelli, RN, BSN
COVID Nurse Coordinator
Phone: 614-487-5035

School Health Offices

High School 
Laurie Long, RN
Lead nurse 
(614) 487-5278
[email protected]
Lisa Fleege, BSN, RN
(614) 487-5100, ext 4003
[email protected]
Jane Mead, RN
(614) 487-5091
[email protected] 
Nikki Kennedy, RN 
(614) 487-5180, ext 5003
[email protected]
Jayna D'Herete, RN 
(614) 487-5050, ext 5517
[email protected]
Ruth Sacolick, RN
(614) 487-5170, ext 6003
[email protected]
Wickliffe and Windermere 
Janice Walsh, RN
Wickliffe Phone: (614) 487-5150, ext 6536 
Wickliffe Email: [email protected]
Windermere Phone: (614) 487-5060, ext 7003
Windermere Email: [email protected]
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