DJJ Form HS049 "Report of on-Site Health Care by Non-health Care Staff" - Florida

What Is DJJ Form HS049?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2006;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form HS049 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form HS049 "Report of on-Site Health Care by Non-health Care Staff" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
REPORT OF ON-SITE HEALTH CARE
BY NON-HEALTH CARE STAFF
Youth’s Name:
Date/Time of Care:
/
DJJID:
Printed Name of Staff Member:
Signature of Staff Member:
I. Instructions:
Direct care and custodial staff who administer first aid/emergency care may document that care on this form.
This form is not to be used to document routine administration of ongoing prescription medications or over-
the-counter medication administration for minor complaints. This form must be filed in the chronological
progress notes of the youth’s Individual Health Care Record. If health care staff are available on-site
part-time, these forms may be collected and given to health care staff at regularly scheduled hours
for their review.
II. Youth Information:
Is youth on Medical Alert?
No
Yes
Youth’s Medical Classification (if known):
1
2
3
4
5
Youth’s allergies (list):
III. Nature of Youth’s Complaint (briefly describe):
IV. Over-the-Counter Medication Given (if any, please list medication and dosage):
V. Other Care Given (if any):
VI. Other Action (May check more than one box):
Placed on Medical Alert
Taken to ER by Staff
Placed on Call-out to see Nurse
Taken to ER by ambulance (EMS)
After-Hours Nurse Consulted by Phone
No further Action Required
After-Hours MD, PA, or ARNP Consulted by Phone
VII.
Parental Notification
Parent/Guardian contacted by phone and informed of youth’s complaint and treatment received.
Name of Parent/Guardian:
Date/Time Informed:
Parental Notification not required.
Parent/Guardian called/Unable to contact.
Parental Notification of Health Related Care mailed. (Copy placed in record.)
Signature of Staff Member Providing Care
Printed Name
Date/Time of Care
HS 049
Save As
Reset/Clear Form
Print Form
P
1
1
AGE
OF
63M-2
. 12/06
REV
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
REPORT OF ON-SITE HEALTH CARE
BY NON-HEALTH CARE STAFF
Youth’s Name:
Date/Time of Care:
/
DJJID:
Printed Name of Staff Member:
Signature of Staff Member:
I. Instructions:
Direct care and custodial staff who administer first aid/emergency care may document that care on this form.
This form is not to be used to document routine administration of ongoing prescription medications or over-
the-counter medication administration for minor complaints. This form must be filed in the chronological
progress notes of the youth’s Individual Health Care Record. If health care staff are available on-site
part-time, these forms may be collected and given to health care staff at regularly scheduled hours
for their review.
II. Youth Information:
Is youth on Medical Alert?
No
Yes
Youth’s Medical Classification (if known):
1
2
3
4
5
Youth’s allergies (list):
III. Nature of Youth’s Complaint (briefly describe):
IV. Over-the-Counter Medication Given (if any, please list medication and dosage):
V. Other Care Given (if any):
VI. Other Action (May check more than one box):
Placed on Medical Alert
Taken to ER by Staff
Placed on Call-out to see Nurse
Taken to ER by ambulance (EMS)
After-Hours Nurse Consulted by Phone
No further Action Required
After-Hours MD, PA, or ARNP Consulted by Phone
VII.
Parental Notification
Parent/Guardian contacted by phone and informed of youth’s complaint and treatment received.
Name of Parent/Guardian:
Date/Time Informed:
Parental Notification not required.
Parent/Guardian called/Unable to contact.
Parental Notification of Health Related Care mailed. (Copy placed in record.)
Signature of Staff Member Providing Care
Printed Name
Date/Time of Care
HS 049
Save As
Reset/Clear Form
Print Form
P
1
1
AGE
OF
63M-2
. 12/06
REV