Guidelines for the Provision of Health Services and/or Section 504 Accommodations




To All Parents and Health Care Practitioners:  

The NYC Department of Education (DOE) and the Office of School Health (OSH) work together to provide services to all students with special needs. These services allow students to fully participate in school. If your child needs health services and accommodations under Section 504 of the Rehabilitation Act, complete the form(s) in this packet. The NYC Department of Education requires a new approval for services each school year

There are three types of health services and accommodations forms: 

  1. Medication Administration Forms (MAFs) – This form is completed by your child’s medical provider to receive medicine or treatment at school.  
    • There are five separate MAFs: asthma; allergies; diabetes; seizures and general.
    • Please submit completed forms to the school nurse.
  2. Medically Prescribed Treatment (Non-Medication) Form – This form is completed by your child’s medical provider to request special procedures such as tube feeding catheterization, suctioning, etc. to be performed at school. This form may be used for all skilled nursing treatments.

o Please submit completed forms to the school nurse.

  1. Request for Section 504 Accommodation(s) – Complete this form to request special services such as a barrierfree building, elevator use, testing modification, etc.
    • Do NOT use this form for related services such as occupational therapy, physical therapy, speech and language therapy, counseling, etc. Related services should be provided through an Individualized Education Program (IEP).
    • There are two separate forms that must be completed: one for parents, and one for your child’s medical provider
    • Please submit completed forms to your school’s 504 Coordinator


  • Please take your child to his or her health care practitioner every year to complete these forms.
  • These forms should be submitted to your school nurse by June 1, 2020 for the new school year. Forms received after this date may delay processing.
  • If the school nurse is unavailable, you may be notified to come to school to give your child medicine.
  • If you decide to use the school’s stock medicine, you must send your child’s epinephrine, asthma inhaler, and other approved self-administered medicines with your child on a school trip day and/or after school programs in order that he/she has it available. Stock medications are for use by OSH staff in school only.
  • Please make sure you sign the back of the form so that your child can receive these services in school
  • Attach a small current photo to the upper left corner of the medication form(s). This helps the school to properly identify your child.

Please reach out to the student’s school nurse and/or the school’s 504 Coordinator if you have any questions. Thank you for your assistance.

Health Care Practitioners: .


Health Care Practitioner Instructions for Completion of the Request for Accommodations Form Please follow these guidelines when completing the forms:

  • Your patient may be treated by several health care practitioners. The health care practitioner completing the form should be the one treating the condition for which services are requested.
  • This form must be completed by the student’s licensed medical provider (MD, DO, NP, PA) who has treated the student and can provide clinical information concerning the medical diagnoses outlined as the basis for this request. Forms cannot be completed by the parent/guardian. Forms cannot be completed by a resident.

All requests for accommodations are based on medical necessity. Please ensure that your answers are complete and accurate. All requests for medical accommodations will be reviewed by the Office of School Health (OSH) clinical staff, who will contact you if additional clarification is needed. There is a school nurse present in most schools. Requests for 1:1 nursing will be reviewed on a case-by-case basis.

  • Please clearly type or print all information on this form. Illegible, incomplete, unsigned or undated forms cannot be processed and will be returned to the student’s parent or guardian.
  • Provide the full name and current diagnoses of clinical relevance for the student.
  • Describe the impact of the diagnoses/symptoms, medical issues, and/or behavioral issues that may affect the student during school hours or transport, including limitations and/or interventions required.
  • Include any documentation and test results for any specialty services or referrals relevant to the accommodations requested.
  • Only request services that are needed during school hours. Do not request medicine that can be given at home, before or after school hours.
  • If a student requires medications or procedures to be performed, please complete and submit all relevant Medication Administration Forms (MAFs) and/or a Request for Medically Prescribed Treatment. The orders should be specific and clearly written. This allows the school nurse to carry it out in a clinically responsible way.
  • Requests for alternative medicines will be reviewed on a case-by-case basis.
  • Clearly print your name and include the valid New York State, New Jersey, or Connecticut license and NPI number.
  • On the Medical Accommodations Request Form: o Please list the days and times that are best to contact you to provide further clarification of the request. o Please sign the attestation documenting that the information provided is accurate.
  • Epinephrine may be stored in the classroom, in a common area, or transported with students as indicated in their Allergy Response Plan.

Student Skill Level: Students should be as self-sufficient as possible in school. Health Care Practitioners must determine whether the child is nurse-dependent, should be supervised, or is independent to take medicine or perform procedures

  • Nurse-Dependent Student: nurse must administer. Medicine is typically stored in a locked cabinet in the medical room.
  • Supervised Student: student self-administers, under adult supervision. The student should be able to identify their medicine, know the correct dose and when to take it, understand the purpose of their medicine, and be able to describe what will happen if it is not taken.
  • Independent Student: student can self-carry/self-administer. For students who are independent, initial the section of the form that allows student to self-administer at school and during trips. Students are never allowed to carry controlled substances.
  • If no skill level is selected, OSH clinical staff will designate the student as nurse-dependent by default,

until further advised by the student’s health care practitioner.


Thank you for your cooperation.

Rev. April 2020