Nursing

Healthcare Plan Cover Page

Health Care Plan Cover Sheet

Student’s Name: ______________________________________ Date of Birth: ___________

School: ________________________ Grade: ______ Teacher: _________________________

Parent/Guardian: ___________________________________ Phone: ____________________

Address:

Resource or Special Ed? Yes No Does student ride the bus? Yes Bus#___

*******************************************************

Medical Diagnosis:
Physician Name/Clinic:
Telephone:
Fax:
Physician Signature:
Date:

I have read and approve Student’s Health Care Plan:

____________________________________ ____________________________________

Principal Date School Nurse Date

____________________________________ ____________________________________

Parent Date School Staff Date

Generic Emergency Action Plan

Printable Generic Emergency Action Plan

Emergency Action Plan (EAP)

Utah Department of Health and Human Services

Utah State Board of Education

Form version: August 2025 (DHHS)

Student Information

Student Name:
Date of Birth:
School Year:
Grade:
School:
Homeroom:
School Phone:
School Fax:
Student Cell Phone Number:
Student Picture: (if applicable)

Parent / Guardian Information

Parent or Guardian 1

Name:
Phone:
Email:

Parent or Guardian 2

Name:
Phone:
Email:

Brief Medical History

Medical Diagnosis:
Description of Condition or Concern:
Baseline Status:

Emergency Action Plan Details

Signs and Symptoms to Watch For

(Describe observable signs or reported symptoms that may indicate an emergency.)

Immediate Actions to Take

(Describe step-by-step actions staff should take in response to symptoms.)

Emergency Protocol

Indicate all that apply:

Call 911
Transport student to (location):
Call parent or emergency contact
Administer emergency medication
Other actions (specify):

Expected Behavior After the Event

Possible observations may include:

Tiredness
Weakness
Sleeping or difficult to arouse
Regular breathing
Other expected behavior (specify):

Follow-Up Actions

Document the incident
Call school nurse
Other follow-up steps (specify):

Special Considerations

1. Special Healthcare Needs

Does the student have special healthcare needs staff should know about?

Examples include tube feedings, oxygen use, respiratory support, seizure precautions.

☐ No
☐ Yes — Description:

2. School-Day Precautions

Are special considerations or precautions needed during the school day?

☐ No
☐ Yes — Description:

3. Transportation Needs

Does the student require special care during transportation?

☐ No
☐ Yes — Description:

Medications

Important Medication Notice

This form alone is not a valid medication authorization. If medication is ordered, a separate Medication Authorization Form must be completed, signed by a healthcare provider, and returned to the school.

Emergency or Rescue Medications

For each medication, document the following:

Medication Name
Dose
Route (e.g., oral, injection)
Time to Administer
Possible Side Effects

Authorized Person to Give Rescue Medication:

☐ School Nurse
☐ Parent
☐ EMS
☐ Volunteer(s) — specify:

Location of Rescue Medication:

Routine Medications

Authorized Person to Give Routine Medication at School:

☐ School Nurse
☐ School Staff — specify:

For each routine medication:

Medication Name
Taken at home or school
Dose
Route
Time
Possible Side Effects

Location of Routine Medication:

Equipment Instructions (If Applicable)

Describe any medical equipment used by the student and clear instructions for staff.

Signatures

Parent Name:
Parent Signature:
Healthcare Provider Name:
Healthcare Provider Signature:
Date:
Provider Phone Number:

Medication Authorization Form

School medication authorization Student medication authorization form Utah Department of Health and Human Services in accordance with UCA 53G-9-501						School year:	Student picture
Student information			Date of birth:
Student name:	School:			Grade:
Parent name:	Phone:			Email:
Prescriber name:	Phone:				Fax:
School nurse name:	School phone:				Fax/email:
Parents must complete this page, sign it, obtain their child’s healthcare provider’s signature, and return the form to the school.
If a request is being made for school staff to administer asthma medication, epinephrine auto-injector, diabetes medication, or seizure rescue medication, an additional form(s) specific to the medication is also required. Those forms must also be signed by the parent and physician and kept on file at the school. These supplemental forms are also required for students to carry and self-administer asthma medication, epinephrine auto-injectors, and diabetes medications. Seizure rescue medication cannot be carried by a student.
As parent/guardian, I request the medication(s) listed below be given to my student during regular school hours. ☐ I understand medication will be administered by trained school employee volunteers. ☐ I understand a new medication authorization form will be required each school year, and whenever there is a dosage change. ☐ I understand I am responsible for maintaining necessary supplies, medications, and equipment. ☐ I understand prescription medication must be transported to and from school by an adult*. ☐ I understand all medications, both prescription and over-the-counter, must be in the manufacturer’s or pharmacy-labeled container, including my student’s name, the medication name, administration time, dosage, and healthcare provider’s name. ☐ I understand the information contained in this order will be shared with school staff on a need-to-know basis. ☐ I understand it is my responsibility to notify the school nurse of any change in my student’s health status or medication order. ☐ I understand that expired medication cannot be administered to my student. I give permission for my student’s healthcare provider to share information with the school nurse for the completion of this medication order.
Parent name:		Phone:
Parent signature:		Date:

*Students may carry some medication in certain circumstances. This applies to asthma medication, epinephrine auto-injectors, and diabetes medications, and only after another form specific to that medication is completed and turned into the school. District and school medication policies may allow students to carry and administer other medications.

Student name:					Student date of birth:
Healthcare provider: this section of the form must be filled out and signed by the student’s healthcare provider. Only an MD/DO, nurse practitioner, certified physician’s assistant, or a provider with prescriptive practice can fill out and sign this section of the form.
Name of medication	Diagnosis/ reason for administration	Dosage	Route	Time		Side effects of the medication



This student is under my care, and I have prescribed this medication(s) for the named student. It is medically necessary for the medication to be administered while the student is at school. ☐ It is medically appropriate for the student to self-carry* this medication, when able and appropriate, and always have possession of this medication and supplies (see statement above under medication Information). This student has been trained to self-administer the medication and can do this safely. ☐ It is not medically appropriate for the student to self-carry and self-administer this medication. Only the appropriate/designated school personnel can maintain this student’s medication for use at school if needed. Other (specify):
Name			Signature				Date
Prescriber:
School nurse:
Principal:
Other:

To be completed by school nurse
Plan of care nursing interventions: ☐ Get parent and licensed prescriber authorization for medications to be given at school. ☐ Administer medication(s) as prescribed. ☐ Train staff who are responsible for the healthcare of the student during the school day on how to properly administer the medication. ☐ Assess staff knowledge related to managing chronic conditions and administering medications, and provide additional training as needed. ☐ Other (specify):		Expected student outcomes ☐ Student has basic health needs met during the school day, enabling regular school attendance. ☐ Student is able to verbalize whom to contact if they experience side effects from their medication. ☐ Student demonstrates improved attendance and participation in school activities. ☐ Other (specify):
☐ Signed by physician and parent	☐ Medication is appropriately labeled		☐ Medication log generated
Medication will be kept: ☐ In the office ☐ In the classroom ☐ Self-carry ☐ Other (specify):
School nurse signature:		Date:

ADD/ADHD

ADD/ADHD – HEALTH CARE PLAN

Student’s Name: ______________________________________________________________________________

This Health Care Plan must be completed by the student’s parent/guardian and their health care provider and returned to the school nurse or the school secretary. (This Health Care Plan should be individualized to meet the student’s specific needs.)

ADD/ADHD (Attention Deficit Disorder with/without Hyperactivity) is a neurobehavioral disorder characterized by developmentally inappropriate inattention, hyperactivity and impulsivity. The person demonstrates a persistent pattern of several abnormal behaviors. The behavior pattern differs from person to person. Diagnosis is difficult and is based on the person’s history and psychological and neurological evaluations. There are not specific medical tests that can diagnose ADD/ADHD.

Problem: The student is to receive treatment medication during school/school activities.

Goal: The student will receive their medication at the scheduled time, as prescribed, from a designated school personnel.

Action: Administer the student’s medication as prescribed on the Authorization to Administer/Carry Medication at School Form.

The student has an abnormally decreased activity in the part of the brain that inhibits their behavior and helps them maintain effort and attention.
When this area is stimulated by medication, the student is more able to sustain attention, focus on their work, control impulsive behavior and aggressiveness and stop fidgeting and running around.
The student should have improved behavior and memory, do better with school work and have improved social adjustments. (However the student’s behavior will not be totally normal.)
The student may need to be reminded to go to the office to receive their medication.

Problem: Potential side effects of stimulant medication in the treatment of ADD/ADHD.

Goal: Potential side effects will be recognized and reported.

Action: Recognize and report the potential side effects of stimulant medication. (The student’s parents/guardian and/or their health care provider to check the appropriate boxes.)

The most common medication side effects are generally minor and short-lived:

Decreased appetite Jitteriness Restlessness

Stomachache Social withdrawal Fast heart rate

Headache Sleeplessness

Stimulant treatment for ADD/ADHD may cause or unmask Tourette’s Syndrome. Notify the parent/guardian and school nurse if the student suddenly displays any of the following: facial twitches, blinking, squinting, repeated sniffing, throat clearing, head jerking, verbal outbursts, grunting, barking, shrieking, coughing, repeating words, stuttering, etc.

Additional information:

Anaphylaxis

Allergy & Anaphylaxis Action Plan

ALLERGY & ANAPHYLAXIS Simplified Individualized Healthcare Plan (IHP)/Emergency Action Plan (EAP)/Medication Authorization and Self-Administration Form In Accordance with UCA 26-41-104 Utah Department of Health/Utah State Board of Education							School Year:	Picture
STUDENT INFORMATION
Asthma: ☐ No ☐ Yes (if yes, high risk for severe reaction, please also complete Asthma Action Plan)
Student:		DOB:		Grade:	School:
Parent:		Phone:			Email:
Physician:		Phone:			Fax or email:
School Nurse:		School Phone:			Fax or email:
ALLERGEN(S)
Allergy to:
☐ If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms. ☐ If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.
Yellow: Mild to Moderate Reaction	Action
MILD Symptoms · Itchy/runny nose · Itchy mouth · A few hives, mild itch · Mild nausea/discomfort	For MILD SYMPTOMS from A SINGLE SYSTEM area, follow the directions below: · Antihistamines may be given, if ordered by a healthcare provider. · Stay with the person; alert emergency contacts. · Watch closely for changes. If symptoms worsen, give epinephrine. For MORE THAN ONE symptom, GIVE EPINEPHRINE
Red: Severe Reaction	Action
SEVERE Symptoms · Short of breath, wheezing, repetitive cough · Skin color is pale, blue, · Faint, weak pulse, dizzy · Tight or hoarse throat, trouble breathing or swallowing · Significant swelling of the tongue and/or lips · Many hives over body, widespread redness · Repetitive vomiting, severe diarrhea · Feeling something bad is about to happen, anxiety, confusion	1. INJECT EPINEPHRINE IMMEDIATELY. 2. Call EMS. Tell them the student is having anaphylaxis and may need epinephrine when they arrive. 3. Lay the person flat, raise legs and keep warm. If breathing is difficult or they are vomiting, let them sit up or lie on their side. 4. Give second dose of epinephrine if symptoms get worse, continue, or do not get better in 5 minutes. 5. Alert emergency contacts. 6. Give other medication (only if prescribed). DO NOT use other medication in place of epinephrine. · Antihistamine · Inhaler (bronchodilator) if wheezing 7. Transport them to emergency department even if symptoms resolve. Person should remain in ED for at least 4 hours because symptoms may return.
MEDICATION
Medication Brand			Dose			Side Effects
Epinephrine:			o 0.15 mg IM o 0.3 mg IM
Antihistamine:
Other: (e.g., inhaler-bronchodilator of wheezing)

Student Name:			DOB:					School Year:
PRESCRIBER TO COMPLETE
The above named student is under my care. The above reflects my plan of care for the above named student. ☐ It is medically appropriate for the student to self-carry Epinephrine Auto Injector (EAI) medication. The student should be in possession of EAI medication and supplies at all times. ☐ Student can self-carry and self-administer EAI if needed, when able and appropriate. ☐ Student can self-carry, but not self-administer EAI. ☐ It is not medically appropriate to carry and self-administer this EAI medication. Please have the appropriate/designated school personnel maintain this student’s medication for use in an emergency. ☐ Additional Orders:
Prescriber Name:				Phone:
Prescriber Signature:				Date:
PARENT TO COMPLETE
Parental Responsibilities: • The parent or guardian is to furnish the Epinephrine Auto Injector medication and bring to the school in the current original pharmacy container and pharmacy label with the student’s name, medication name, administration time, medication dosage, and healthcare provider’s name. • The parent or guardian, or other designated adult will deliver to the school and replace the Epinephrine Auto Injector medication within two weeks if the Epinephrine Auto Injector single dose medication is given. • If a student has a change in their prescription, the parent or guardian is responsible for providing the newly prescribed information and dosing information as described above to the school. The parent or guardian will complete an updated Epinephrine Auto Injector Medication Authorization and Self-Administration Form (this form) before the designated staff can administer the updated Epinephrine Auto Injector medication prescription.
Parent/Guardian Authorization ☐ I authorize my student to carry the prescribed medication described above. My student is responsible for, and capable of, possessing an epinephrine auto-injector per UCA 26-41-104. My student and I understand there are serious consequences for sharing any medication with others. ☐ I authorize my student to self-carry and self-administer EAI if needed, when able and appropriate. ☐ I authorize my student to self-carry, but not self-administer EAI. o I do not authorize my student to carry and self-administer this medication. Please have the appropriate/designated school personnel maintain my student’s medication for use in an emergency.
Parent Signature:							Date:
As parent/guardian of the above named student, I give my permission to the school nurse and other designated staff to administer medication and follow protocol as identified in this emergency action plan. I agree to release, indemnify, and hold harmless the above from lawsuits, claim expense, demand or action, etc., against them for helping this student with allergy/anaphylaxis treatment, provided the personnel are following prescriber instruction as written in the emergency action plan above. Parent/Guardians and students are responsible for maintaining necessary supplies, medication and equipment. I give permission for communication between the prescribing health care provider and the school nurse if necessary for allergy management and administration of medication. I understand that the information contained in this plan will be shared with school staff on a need-to-know basis and that it is the responsibility of the parent/guardian to notify school staff whenever there is any change in the student’s health status or care.
Parent Name (print):		Signature:							Date:
Emergency Contact Name:		Relationship:							Phone:
SCHOOL NURSE (or principal designee if no school nurse)
☐ Signed by prescriber and parent	☐ Medication is appropriately labeled					☐ Medication Log generated
EAI is kept: ☐Student Carries ☐Backpack ☐Classroom ☐ Health Office ☐ Front Office ☐ Other (specify):
Allergy & Anaphylaxis EAP distributed to ‘need to know’ staff: ☐ Teacher(s) ☐ PE teacher(s) ☐ Transportation ☐ Front Office/Admin ☐Other (specify):
School Nurse Signature:					Date:

Special Diet Requests

Diet Prescription for School Meals Tooele County School District

Student Name: ________________________________

School: ________________________________

Grade: ________________________________

Date of Birth: ____ / ____ / ______

Parent/Guardian Name: ________________________________

Parent/Guardian Phone #: ________________________________

Email: ________________________________

TO BE COMPLETED BY MEDICAL AUTHORITY (Medical Physician (M.D.), Physician Assistant (P.A.), Osteopathic Physician (D.O.), Advanced Practice Registered Nurse (A.P.R.N.), Naturopathic Physician (N.D.))

Medical condition or disability requiring a special meal, accommodation, or substitute:

According to the ADA Amendments Act of 2008, the term “disability” means, with respect to an individual, “a physical or mental impairment that substantially limits one or more major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment.”

Provide a description of the major life activities or bodily functions affected by the condition:

Check all symptoms that apply:

[ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Itching / Swelling [ ] Rash [ ] Wheezing / Cough [ ] Other: _________________________________________________________________

DIETARY RESTRICTIONS AND SUBSTITUTIONS

DAIRY [ ] Milk Allergy [ ] Lactose Intolerance [ ] Other: _________________________________________________________________

Foods to omit (check all that apply): [ ] Fluid milk [ ] All ingredients containing milk [ ] Cheese [ ] Yogurt [ ] Butter [ ] Baked goods made with milk [ ] Other, specify: _________________________________________________________

Allowed substitute (check all that apply): [ ] Lactose-free milk [ ] Plant-based milk alternatives [ ] Dairy-free food options [ ] Other, specify: _________________________________________________________

EGGS [ ] Egg Allergy [ ] Other: _________________________________________________________________

Foods to omit (check all that apply): [ ] Eggs [ ] Baked goods containing eggs [ ] Other, specify: _________________________________________________________

Allowed substitute (check all that apply): [ ] Egg-free protein options [ ] Egg-free baked goods [ ] Other, specify: _________________________________________________________

GRAINS [ ] Wheat Allergy [ ] Celiac Disease [ ] Gluten Intolerance [ ] Other: _________________________________________________________________

Foods to omit (check all that apply): [ ] Wheat [ ] Condiments [ ] Rye [ ] Oats [ ] Barley [ ] Other, specify: _________________________________________________________

Allowed substitute (check all that apply): [ ] Gluten-free alternative grains [ ] Wheat-free alternative grains [ ] Rice [ ] Corn products [ ] Other, specify: _________________________________________________________

PEANUTS / TREE NUTS [ ] Peanut Allergy [ ] Tree Nut Allergy [ ] Other: _________________________________________________________________

Foods to omit (check all that apply): [ ] Peanuts and peanut butter [ ] Peanut oil [ ] All tree nuts and nut butters [ ] Other, specify: _________________________________________________________

Allowed substitute (check all that apply): [ ] Soy butter [ ] Sunflower seed butter [ ] Nut-free protein options [ ] Other, specify: _________________________________________________________

SEAFOOD [ ] Fish Allergy [ ] Shellfish Allergy [ ] Other: _________________________________________________________________

Foods to omit (check all that apply): [ ] Crustaceans (crab, shrimp, lobster) [ ] Mollusks (clam, mussel, oyster, scallop) [ ] Finned fish [ ] Anchovy as an ingredient [ ] Imitation fish/crab [ ] Other, specify: _________________________________________________________

Allowed substitute (check all that apply): [ ] Non-fish protein options [ ] Other, specify: _________________________________________________________

SOY [ ] Soy Allergy [ ] Other: _________________________________________________________________

Foods to omit (check all that apply): [ ] Soy protein [ ] Soy lecithin [ ] Other, specify: _________________________________________________________

Allowed substitute (check all that apply): [ ] Soy-free options [ ] Other, specify: _________________________________________________________

OTHER CONDITION

Other condition (describe):

Foods to omit: [ ] ________________________________________________________________________ [ ] ________________________________________________________________________ [ ] ________________________________________________________________________

Allowed substitutes: [ ] ________________________________________________________________________ [ ] ________________________________________________________________________ [ ] ________________________________________________________________________

ALTERED TEXTURE AND ADAPTIVE EQUIPMENT

Texture (check one): [ ] Regular [ ] Chopped [ ] Ground [ ] Pureed

Adaptive equipment (if needed):

SIGNATURES

Signature of Medical Authority & Credentials:

Printed Name: ________________________________ Date: ____ / ____ / ______

Doctor’s Office Phone Number: ________________________________________________

CNP Manager: ________________________________ Date: ____ / ____ / ______

School Nurse: ________________________________ Date: ____ / ____ / ______

Parent/Guardian: _____________________________ Date: ____ / ____ / ______

This information may be shared with kitchen and administrative staff to accommodate the student in all school activities. This institution is an equal opportunity provider.

Peanut-Free Zone Sign

Please do not bring any peanuts or products containing peanuts into area.

Thank you for helping to keep our children safe.

Anxiety/Panic Disorder

Anxiety / Panic Disorder – Health Care Plan
Student Information
Student’s Name: _______________________________________________

Purpose of This Plan
This Health Care Plan must be completed by the student’s parent or guardian and the student’s health care provider.
The completed plan must be returned to the school nurse or school secretary.
This plan should be individualized to meet the student’s specific needs.

Condition Overview
Anxiety / Panic Disorder is a disabling condition that may impair a child’s behavior. It can affect:

School performance
Social activities

If untreated or unmanaged, anxiety and panic disorder can lead to serious problems such as substance abuse, loss of employment, and suicide.

Problem 1: Anxiety and Panic Episodes
Goal
Reduce anxiety and panic symptoms.

Action Plan
The student will avoid known triggers.
School personnel will assist the student in avoiding known triggers.
(The student’s parent/guardian and/or health care provider should indicate appropriate selections below.)

Frequency of Panic Attacks
Panic attacks usually occur:

☐ Daily
☐ Weekly
☐ Monthly

Observation Guidance:
School personnel should observe patterns and possible precipitating events.
As the frequency of panic attacks increases, the student may begin to avoid situations for fear of another attack.

Student’s Symptoms
The student may experience the following symptoms:

☐ Anxiety
☐ Chest pain
☐ Rapid heartbeat
☐ Nausea
☐ Dizziness
☐ Shortness of breath
☐ Intense fear
☐ Fear of dying

Other symptoms (please list):

Problem 2: Medication Management
Goal
Ensure early recognition and reporting of medication side effects.

Action Plan
Side effects from medications that must be reported to the parent or physician include:

☐ Lethargy
☐ Dizziness
☐ Weakness
☐ Fatigue
☐ Confusion
☐ Headache

Other side effects (specify):

Additional Information
Please provide any additional information relevant to the student’s anxiety or panic disorder, care needs, or accommodations:

Signatures / Authorization (if applicable)

Asthma

Asthma Care Plan

Asthma Action Plan (AAP) Individualized Healthcare Plan (IHP)/Emergency Action Plan (EAP)/Medication Authorization & Self-Administration Form in accordance with UCA 26-41-104 Utah Department of Health/Utah State Board of Education							School Year:			Picture
STUDENT INFORMATION
Student:			DOB:		Grade:		School:
Parent:			Phone:				Email:
Physician:			Phone:				Fax or email:
School Nurse:			School Phone:				Fax or email:
Severity Classification ¨ Intermittent ¨ Mild Persistent ¨ Moderate Persistent ¨ Severe Persistent Triggers ¨ Illness ¨ Exercise ¨ Animals ¨ Smoke ¨ Dust ¨ Food ¨ Weather ¨ Air Quality ¨ Pollen ¨ Other (specify):
Air Quality Student should stay indoors when Air Quality Index is:						Exercise Take quick-relief medication (see medication order in Yellow section below): ☐ Before exercise/exposure to a trigger ☐ Other (specify):
o Moderate	o Unhealthy for sensitive groups	o Unhealthy		o Other:
Green: Doing Great!			Action
Student has ALL of these: - Breathing is easy - No cough or wheeze - Able to work and play normally			Controller Medication (taken at home)				How Much?		How Often?

Yellow: Mild to Moderate Distress			Action
Student has ANY of these: - Coughing or wheezing - Tight chest - Shortness of breath - Waking up at night			Quick-Relief Medication					How Much?		How Often?

			Administer Via					o Student is independent o Student needs assistance o Student needs supervision
			o Inhaler o Nebulizer o Inhaler with spacer
			1. Restrict physical activity and allow to rest upright. 2. Do not leave student unattended. Observe continuously for 15 minutes. 3. Notify parent/guardian. 4. If improved (breathing smooth and easy, no coughing or wheezing) may return to class. 5. If no improvement call EMS and move to Red section below.
Red: Severe Respiratory Distress			Action
Student has ANY of these: - Trouble eating, walking or talking - Breathing hard and fast - Medicine isn't helping - Rib or neck muscles show when breathing in - Color changes in lips, nail beds, skin			Call EMS! 1. Repeat____ puffs of Quick-Relief Medication (each 15-30 seconds apart) every minutes until medical help arrives. 2. Encourage slow breaths and allow individual to rest. 3. Update parent/guardian. 4. Do not leave student unattended. Observe continuously until EMS arrives ☐ Additional Orders (specify):

Student Name:				DOB:			School Year:
PRESCRIBER TO COMPLETE
The above named student is under my care. The above reflects my plan of care for the above named student. ☐ It is medically appropriate for the student to carry and self-administer asthma medication, when able and appropriate, and be in possession of asthma medication and supplies at all times. ☐ It is not medically appropriate for the student to carry and self-administer this asthma medication. Please have the appropriate/designated school personnel maintain this student’s medication for use if having symptoms at school.
Prescriber Name:			Phone:
Prescriber Signature:			Date:
PARENT TO COMPLETE
Parental Responsibilities: • The parent or guardian is to furnish the asthma medication and bring to the school in the current original pharmacy container and pharmacy label with the child’s name, medication name, administration time, medication dosage, and healthcare provider’s name. • The parent or guardian, or other designated adult will deliver to the school and replace the asthma medication when empty. • If a student has a change in their prescription, the parent or guardian is responsible for providing the newly prescribed information and dose information as described above to the school. The parent or guardian will complete an updated Asthma Action Plan before designated staff can administer the updated asthma medication prescription.
Parent/Guardian Authorization ☐ I authorize my child to carry and self-administer the prescribed medication described above. My student is responsible for, and capable of, possessing or possessing and self-administering an asthma inhaler per UCA 53G-9-503. My child and I understand there are serious consequences for sharing any medication with others. ☐ I do not authorize my child to carry and self-administer this medication. Please have the appropriate/designated school personnel maintain my child’s medication for use in an emergency. ☐ I authorize the appropriate/designated school personnel maintain my child’s medication for use in emergency.
Parent Signature:							Date:
As parent/guardian of the above named student, I give my permission to the school nurse and other designated staff to administer medication and follow protocol as identified in the asthma action plan. I agree to release, indemnify, and hold harmless the above from lawsuits, claim expense, demand or action, etc., against them for helping this student with asthma treatment, provided the personnel are following prescriber instruction as written in the asthma action plan above. Parent/Guardians and students are responsible for maintaining necessary supplies, medication and equipment. I give permission for communication between the prescribing health care provider, the school nurse, the school medical advisor and school-based clinic providers necessary for asthma management and administration of medication. I understand that the information contained in this plan will be shared with school staff on a need-to-know basis and that it is the responsibility of the parent/guardian to notify school staff whenever there is any change in the student’s health status or care.
Parent Name:		Signature:					Date:
Emergency Contact Name:		Relationship:					Phone:
SCHOOL NURSE (or principal designee if no school nurse)
☐ Signed by prescriber and parent	☐ Medication is appropriately labeled					☐ Medication log generated
Medication is kept: ☐Student Carries ☐Backpack ☐Classroom ☐ Health Office ☐ Front Office ☐ Other (specify):
Asthma Action Plan distributed to ‘need to know’ staff: ☐ Teacher(s) ☐ PE teacher(s) ☐ Transportation ☐ Front Office/Admin ☐Other (specify):
School Nurse Signature:					Date:

Asthma Emergency Protocol

Green Zone: Routine Therapy

If student is:

breathing easily
not coughing or wheezing
not short of breath
able to work and play easily

Avoid these possible asthma triggers:

Dust mites, mold, chemicals, changes in temperature, tobacco smoke, pets, exercise, stress, and cockroaches.

QUICK RELIEF Medicines

Take 5 minutes prior to exercise or unavoidable trigger exposure.

Yellow Zone: Step Up Therapy

If student is:

coughing
wheezing
short of breath
having difficulty breathing during activity

Take QUICK RELIEF Medicines.

Encourage student to:

rest in a comfortable position, but not lying down
relax and take slow deep breaths

Monitor Symptoms

If symptoms RESOLVE within 15 minutes, student may return to class.
If symptoms PERSIST or return within a few hours, follow red zone directions and contact parent.

Red Zone: Get Help NOW!

If:

medicine is not helping
breathing is very difficult
breathing difficulty limits mild activity or speaking
speaking makes student short of breath

Take QUICK RELIEF Medicines.

If red zone symptoms persist, call 911.
If symptoms do not improve, repeat previous QUICK RELIEF doses and watch student closely until ambulance arrives.

DO NOT try and treat severe symptoms yourself.

This is a general guide only; some individuals’ asthma worsens quickly.
When in doubt, call 911.

Celiac

CELIAC DISEASE - HEALTH CARE PLAN

Student’s Name: ______________________________________________________________________________

Celiac Disease (Sprue) is a disorder of the small intestine characterized by permanent inability to tolerate dietary gluten (a protein found in wheat and other grain products). When a person with celiac disease eats foods containing gluten, an immune reaction occurs in the small intestine, resulting in damage to the surface of the small intestine and an inability to absorb certain nutrients from food. This condition is manifested by diarrhea, malnutrition, and a bleeding tendency. No treatment can cure celiac disease. However, you can effectively manage celiac disease through changing your diet. Treatment consists of a lifelong gluten-free diet, adequate caloric intake, supplemental vitamins and minerals, reduced fat intake and close monitoring for celiac crisis.

Problem: Care must be taken to follow the recommended diet.

Goal: Maintain gluten-free diet.

Action:

Must avoid all foods containing wheat, rye, oats, and barley. This includes prepackaged foods that may have these products added.

May have classroom treats if they are gluten-free.

o Gluten containing grains are: wheat, rye, barley, malt, and oats.

o Substitute gluten-free foods such as: rice, corn, and soybean products.

o Avoid foods with addititives that may contain gluten. Read labels carefully. If there is any questions, contact parent before giving.

These foods can be given: fruits, vegetables, milk, juice, popcorn, and rice cakes.

Avoid these foods: salad dressing, ice cream, breads, cookies, pasta, vinegar, ketchup, candy, hot dogs, cream soups, processed cheese, cocoa and chocolate, or other products made with grains or modified food starch.

Problem: Celiac Crisis

Goal: Early recognition and reporting for celiac crisis.

Action:

1. Symptoms of celiac crisis include: Severe vomiting and diarrhea, weight loss, depressed affect, immobility, grossly distended abdomen, and marked dehydration.

2. Although celiac crisis is extremely rare, any of the above symptoms should be reported to the parent and school nurse immediately.

Additional Information: