START Nurse Survey (Student Name in Email)

Concern for the following student has been brought to the attention of the Student Assistance Team. Please note your observations on this form. This information will be used to help the student and his or her family to clarify the concern and determine an appropriate action.
Name: 


A red asterisk (*) indicates required questions.

  1. Your identity will not be seen on the collected data print out, or disclosed to the parent/student. Would you prefer a member of the Student Assistance Team to contact you instead of completing this form?*
    Yes, please contact me.
    No, I will complete this form.


  1. Please the number of visits to the nurse's office for this student, with a summary of the reasons for these visits:


  1. Please the number of times this student was sent home, with a summary of the reasons for these dismissals:


  1. List any significant medical problem(s):


  1. If you have had any contact with the parent/guardian, please explain:


  1. Current/past medication(s):


  1. Please check all that you have observed about this student.

    Physical Attributes
    Noticeable change in weight
    Unsteady on feet
    Complaining of nausea/stomach aches
    Glassy/bloodshot eyes
    Unexplained physical injuries (please explain below)
    Poor motor skills
    Frequent cold-like symptoms
    Smelling of alcohol/marijuana
    Slurred speech
    Loss of hair
    Self-injury / self-harm
    Poor hygiene
    Frequently expresses concern with personal health issues
    Fatigue
    Disoriented
    Headaches
    Food issues (explain in details section)
    Expresses negative perception of body image (explain in details section)
    Sleeping in class


  1. Please explain any details from the Physical Attributes section:


  1. Crisis Indicators
    Crisis intervention for suicide
    Has expressed desire to join someone who has died
    Has made suicidal threats/gestures
    Recent death of a family member or close friend
    Exhibits self-harming behaviors
    Expresses indicators of living in an at-risk environment (explain in details section)
    Other stressors (explain in details section)


  1. Please explain any details from the Crisis Indicators section:


  1. Atypical Behavior
    Cries
    Openly expresses alcohol / other drug use
    Inappropriate sexual verbalization
    Expresses involvement in the occult
    Expresses involvement in hate groups
    Expresses hopelessness, worthlessness, helplessness
    Expresses fear or anxiety (explain in details section)
    Expresses anger towards parent or other authority figure
    Lies
    Criticizes others/self
    Seeks constant reassurance
    Dramatic/sudden change in behavior (explain in details section)


  1. Please explain any details from the Atypical Behavior section:


  1. In the space below, please indicate any other known stressors:





Mrs. Graham
Science Teacher
Central Bucks HS South
Doylestown, PA