Pearl Harbor Kai Elementary

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Mrs. Casey Leeds » Health Room

Health Room

Aloha Parents!
   Welcome to Mrs. Casey's Health Room. Here at Pearl Harbor Kai Elementary School, we believe that “Healthy Children Learn Best”! I work hand in hand with the Hawaii Department of Health Nurses to provide excellent care for your children. My office is always open. Please don't hesitate to contact me. You will find links on my page for helpful information for both current and new students. 

School Health Requirement Notice


In accordance with Hawaii State Administrative Rules 11-157-3.2c; 11-157-6.1; 11-157-3.05


Please provide the following documents at time of registration. You may refer to the Hawaii State DOH Notice provided in a link below for additional information and FAQs.

1. Tuberculosis Clearance (PPD/Mantoux): Must be presented at time of registration
     and include the following.
                         a. Performed within 12 months of first entry into a HIDOE school.
                         b. Date TB administered.
                         c. Date TB read.
                         d. Measurement of result in mm.
                         e. Signature of U.S. licensed medical professional providing the TB clearance.
 2. Physical Examination (PE/Form 14) 
                        a. Performed within 12 months of first entry into a HIDOE school.
                        b. Completed on a DOE School Health Record (Form 14)
                              * Alternative physical forms will be accepted on a temporary basis. Please
                                have PE transcribed onto a Form 14 and signed by physician. Turn into
                                Health Room once completed.
3. All required immunizations.



Medication Administration Forms and Instructions

The following forms are required for Medication Administration in all Hawaii DOE schools. They expire at the end of every school year, and must be renewed each year. Please print and complete all 4 forms and turn them in to the Health Room.

  1. SH36: This is a 2 part form, to be completed in it's entirety by both a parent and your child's physician. 
  2. PHN 28 School: There are 2 separate PHN 28 forms. The first is giving the DOE (our school) permission to share information with the DOH (our public health nurse).
  3. PHN 28 MD: The second is giving the DOH permission to share information with your child's physician.
  4. PHNBB: This is a Notice of Privacy Practices form that requires a signature and date. 


If your child requires 
Daily Medication
Emergency Medication
(Epi Pen/INH)
during school hours, the following forms must be COMPLETED and

APPROVED prior to storing and administering at school. The forms, and instructions for completing them are located below.