My name is Mrs. Koucheravy and I am the School Nurse at St. Bernadette School.  I am eager to work with you to keep our children healthy and in school! It is well documented that HEALTHY children learn better.



Angela Koucheravy, RN, BBA

Fax: 703-269-1116

Telephone: 703-451-8696 

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  1. School Entrance Health Form, Commonwealth of Virginia 
  2. School Health Entrance Form, Instructions 
  3. Office of Catholic Schools Diocese Of Arlington, Confidential Student Health History Update (Complete this Form at the Beginning of Each School Year)
  4. Certificate of Religious Exemption (for Immunization)
  5. Permission for Emergency Care 
  6. Medication Authorization Form (Not for Epinephrine, Inhaler, or Antihistamine Authorization)
  7. Epinephrine Authorization Form 
  8. Asthma Action Plan (Must include Inhaler Authorization Form #10 below) 
  9. Allergy Action Plan (Must Include Epinephrine Authorization #7 above, and Antihistamine Authorization Form #11 below in Packet) 
  10. Inhaler Authorization Form 
  11. Antihistamine Authorization 
  12. Diabetes Medical Management Plan 
  13. Diabetes Reference Emergency Plan for Hypoglycemia and Hyperglycemia 
  14. Confidential Health History Update Form 
  15. Dental Form
  16. Form for Food Allergy other than Nuts


Forms Needed for Food Allergy

     1. Allergy Action Plan (#9 above)

     2. Epinephrine Authorization Form (#7 above)
     3. Antihistamine Authorization (#11 above)


Forms Needed for Asthma

    1. Asthma Action Plan (#8 above)
    2. Inhaler Authorization Form (#10 above)



Immunization Requirements 

The Commonwealth of Virginia requires that students have certain immunizations while attending school. Please refer to the following from the Virginia Department of Health immunization requirements.  

Some additional links to important immunization information are as follows:


When to Keep Your Sick Child Home From School

If your child will be staying home from school, please inform the school about the symptoms your child is experiencing or any physician diagnosis they have received.

Children should stay home from school if they’ve had any of these symptoms during the last 24 hours :

  1. Temperature of 100 degrees or greater (child should be free of fever 24 hours without medication before returning to school).
  2. Vomiting or Diarrhea (it is recommended that a physician be contacted if the vomiting and diarrhea last longer than 24 hours or becomes severe.)
  3. Unusual or unexplained rash.
  4. Severe cough or cold with temperature of 100 degrees or greater.
  5. Strep throat (following a positive throat culture the child may attend school 24 hours after antibiotic treatment is begun and the child is fever free.)

Use of Crutches 

An order from a Licensed Healthcare Provider is required to use crutches at school. If a student arrives at school on crutches without a doctor’s order, the parent will be called to take the student home.

Additional Information

Last modified on Wednesday, 11 December 2019 11:04