Adopted:          09/15/2008

                                                                                               453.1 Exhibit (1)

School District of Prairie Farm

Prairie Farm School District

Head Lice Treatment Verification

In order for a student to be readmitted, this form is to be completed and signed by the parent/guardian and must accompany the student on the day of his/her return to school. This information is not included in your child’s permanent record, but shall be maintained by the District school nurse(s) for the remainder of the school year.

First Treatment

Name of Student: _____________________ School: ______________________

Name of medication (shampoo or rinse) used in treatment: ________________________

My child has received treatment for head lice and has complied with the Prairie Farm School District Treatment Guidelines in accordance with the State of Wisconsin Division of Health guidelines.

____________________________________ ______________________________

Signature of parent/guardian                                                      Date