District Information
District 504 Forms
District Health Check Off Forms
- 2023_ All Health Requirements.pdf
- 2023_ New Student Health Check Off.pdf
- 2023_ Pre-K Health Check Off.pdf
- 2023_ Kindergarten Health Check Off.pdf
- 2023_ 2nd grade Health Check Off.pdf
- 2023_ 6th grade Health Check Off.pdf
- 2023_ 9th grade Health Check Off.pdf
- 2023_ 12th grade Health Check Off.pdf
District Health Action Plans
- Asthma Action Plan
- Asthma Questionnaire
- Bee Sting Allergy Action Plan
- Food Allergy Action Plan
- Seizure Action Plan
- Seizure Questionnaire
- Western Asthma Action Plan
Illinois Health Forms
- Child Health Exam Form
- Child Health Exam Form (Spanish Version)
- Childhood Lead Risk Questionnaire
- IL Dental Exam Form
- IL Dental Exam Waiver Form
- Illinois Certificate of Religious Exemption Form
- Illinois Eye Exam Form
- Illinois Eye Exam Waiver Form
- Illinois Sports Physical Form
Medication Authorization
Peanut Allergy Resources
- Classroom Peanut Letter
- Peanut-Free Snack List
- My Classmate Has a Food Allergy
- My Student Has a Food Allergy
Western Immunization Summary
- Western District Immunization Summary 2019-2020
- Western Immunizations 21-22
- Western Immunizations 22-23
Asthma Protocol
Western CUSD 12 is formally requesting parent/guardians of a student with an asthma diagnosis to submit an Asthma Action Plan completed by student’s health care provider to the Health Office. This plan is written and developed by a student’s medical provider to help control the student’s asthma and gives detailed instructions on how to treat Asthma symptoms. This request is stemming from Illinois Public Act 099-0843, which requires schools to request this information on all students with a diagnosis of Asthma. Illinois Public Act 099-0843 also required School Districts in Illinois to develop an “Asthma Episode Emergency Response Protocol,” which are the procedures to provide assistance to a student experiencing symptoms of wheezing, coughing, shortness of breath, chest tightness, or breathing difficulty. More information on Illinois Public Act 099-0843 can be located on the Illinois General Assembly website. If questions arise regarding this, please contact the School Nurse at 217-335-2323 or contact your student’s building administrator.
Western Concussion Protocol
- Concussion Return to School Health Care Prover
- Concussion Signs and Symptoms Check List
- Heads up- Student Returning to school after concussion for Staff-Fact Sheet
- Heads up-signs and symptoms of concussion
- HeadsUp-Concussion information for parents-student
- HeadsUpConcussion- Parent information
- HeadsUpConcussion- School Professionals Fact Sheet
- HeadsUpConcussion-Action Plan
- HeadsUpConcussion-Coach Fact Sheet
- HeadsUpConcussion-High School Athlete Fact Sheet
- HeadsUpConcussion-Middle School Athlete Fact Sheet
- Western Concussion Management Protocol