Protocols

Helpful Links

Protocols

Each Specialized Physical Healthcare Service (SPHCS) or protocol has a specific authorization form posted under the protocol guidelines.

Other Protocol Forms, Generic Authorization Forms and Protocol Training Video Links

A. Specialized Health Care Services:

(1) SPHCS Form 2025/2026

(2) Guidelines

B. Authorization Forms

(1) Generic Protocol Authorization Form

(2) Blood Glucose Test Authorization Form

(3) Tx of Hypolycemia Form

B. Training Video Links (updated 11/7/23)

C.Agency Agreement Form

D. Orientation of NPA LNP

E. For a protocol or SPHCS that is not listed on the standardized specialized physical health care services, please download the Generic Authorization Form (English)

F. General Guidelines for Orientation of LNP

G. Licensed Nursing Provider

H. Nursing Protocol Log

I. Protocol and Medication Training & Supervision Checklist Form- for Licensed and Unlicensed

Assistive Personnel

J. Training Log: (1) Student Specific Training Log (2) Training Log

Information | Training Logs Access: DNS

DNS Training Logs are submitted at: Submit Training Logs
All submitted training logs (Student Specific, General, and Supervisor Checklist) are housed on SharePoint: Access Submitted Training Logs

JOB AID: Downloading Training Records from SharePoint

Contact your Nursing Coordinator if:

You can’t access the Training Log SharePoint Link
A training log needs to be marked as an error (provide explanation)

K. Review of Support Services Due to Health Needs- Complete for Student with Protocol Before the IEP Meeting

L. SPHCS (Protocols) Supplies & Services Location Information Form

Adrenal Insufficiency

Anaphylaxis

Protocols Guidelines: Anaphylaxis Protocol, November 2024

Bulletin: BUL-5628.1: Management of Food/Other Severe Allergies and Epinephrine Auto-Injector Use

Attachments:

Attachment A Printer Friendly Version - Authorization Form November 2024

Attachment B - Anaphylaxis Guidelines

Attachment C - Letter Template

Attachment D - Special Diet Form.

*****For the most recent version of the Special Diet form, click here.

Forms:

1. Emergency Care Plan

2. Confidential Health Info - Severe Allergies

Epipen Standing Order:

Region North (Valley East)

Region North (Valley West)

Training:

Training Video: Anaphylaxis

Training Video | Epinephrine Auto-injector Administration

FOR SCHOOL BASED CLINIC USE ONLY: A naphylactic Reaction Clinic Emergency Protocol - October 2025

Autonomic Dysreflexia

Catheterization

a. Clean Catheterization Guidelines (3/2019)

Authorization Form for Clean Catheterization (1/2025): English/Spanish

b. Clean Self-Catheterization with Assistance Guidelines (3/2019)

Authorization Form for Clean Self-Catheterization with Assistance (1/2025) English/Spanish

c. Clean Self-Catheterization Guidelines (3/2019)

Authorization Form for Clean Self-Catherization (1/2025) English/Spanish

d. Sterile Catheterization Guidelines (3/2019)

Authorization Form for Sterile Catheterization (1/2025) English/Spanish

e. Training Videos Link

Diabetes Protocols

Guidelines:

Baqsimi(Glucagon Nasal Spray/Severe Hypoglycemia) (12/2021)
Blood Glucose Testing (3/2019)
Carbohydrate Counting and Insulin Coverage Calculation in School Setting, 6/3/2025
Continuous Glucose Monitoring (CGM) Guidelines, 5/2025
Glucagon Injection(Severe Hypoglycemia) (3/2019)
Glucagon Training Video
Gvoke Hypopen Guidelines, 6/2025
Hyperglycemia Treatment (Ketone Testing) (3/2019)
Hypoglycemia Treatment (3/2019)
i-Port Advance Guidelines, 6/2025
Insulin Administration with Insulin Pen, 6/2025
Insulin Administration with Vial and Syringe, 6/2025

Authorization Forms:

a. Diabetes Medical Management Plan (DMMP) - Health Care Provider Authorization and Parent Consent, 6/2025

b. Parents’/Guardians’ Authorization & Student Contract: Diabetes Independent Care/Self-Care, 6/2024

Non-Diabetes Protocol Authorization Forms:

Hyperinsulinemia Management Plan Related to Non-Diabetes Conditions

Non-Diabetes Hypoglycemia Emergency Plan

Other Related Forms and Information:

a.Confidential Health Information - Diabetes Oct. 2024

b. Diabetes Emergency Care Plan, 2/2025

c. Diabetes Order Checklist for School Use, 6/2025

d. Diabetes Protocol Log, 1/2025

e. Diabetes Skills Performance Evaluation, 2/2025

f. Student with Diabetes

g. Training Video

Diabetes Management Resources:

For LAUSD Food Services Web Page for Menu click here; for carbohydrate count click here .

Epinephrine for Schools (SB1266)

Gastrostomy and Jejunostomy

Gastrostomy

a. Gastrostomy Feeding: Bolus Method (3/2019)

Authorization Form (7/2024): English/Spanish

b. Gastrostomy Feedings: Slow Drip Method or Pump(3/2019)

Authorization Form (7/2024): English/Spanish

c. Gastrostomy Tube Replacement (3/2019)

Authorization Form (7/2024): English/Spanish

d. Training Videos Link

Jejunostomy

Jejunostomy Tube Feeding: Slow Drip Method or Pump (3/2019)

Authorization Form (2/2025): English/Spanish

Protocol Related Form: Special Diet Form

Hyperinsulinemia and Hypoglycemia - Non Diabetes Management Plan

LifeVac Protocol

Mechanical Nebulizer

Mechanical Ventilation

Mechanical Ventilation Guidelines (3/2019)

Authorization Form for Mechanical Ventilation (2/2025): English/Spanish

Other Related Forms/Information

1. Agency Agreement

2. Daily Mechanical Ventilator Checklist (Rev. 6/2015)

3.General Guidelines for Orientation of Pupil

4. Licensed Nursing Provider

5. Manual Resuscitation Bag

6. Mechanical Ventilator Definitions

7. Mechanical Ventilation Prescription Form

Ostomy Care

Oxygen Therapy + Pulse Oximetry

Seizure Care

Protocols:

1. Seizure Care: Nasal Benzodiazepine 8/2021

Authorization Form: English/Spanish (2/2025)

2. Diastat - Diastat Guidelines (3/2019)

Authorization Form (2/2025): English/Spanish

3. Vagus Nerve Stimulation (VNS) - VNS Guidelines (3/2019)

Authorization Form (3/2023): English/Spanish

Related Forms and Information

a. Confidential Health Information for Student with Seizures

b. Seizure Action Plan: English/Spanish

c. Seizure Record

d. Parent Questionnaire for Students with Seizures: English/Spanish | English/Korean

e. Request for Medication During School Hours

English - Chinese

English - Korean

English - Russian

English - Spanish

Training Videos

1. Training Video: Seizure_Diastat (updated 11/7/23)

2. Training Video: Valtoco

3. DNS PD: Seizure Management Field Trip Clearance, Sept. 14, 2021

Suctioning

Protocols

1. Oral Nasal Suctioning (3/2019)

Authorization Form for Oral/Nasal Suctioning (2/2025): English/Spanish

2. Oropharyngeal and Nasopharyngeal Suctioning (3/2019)

Authorization Form: (2/2025): English/Spanish

3. Tracheostomy Suctioning(3/2019)

Authorization Form: (2/2025): English/Spanish

4. Tracheostomy Tube Replacement(3/2019)

Authorization Form (2/2025): English/Spanish

Training Videos Link and Related Forms:

Reporting

Employees

Quick Links

Contact Information

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Los Angeles, CA 90012
P: (213) 202-7580
F: (213) 580-6557
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Director:
Sosse Bedrossian, MSN, MA, RN, FNP