To be completed by healthcare provider
|
|
- Sydney Haynes
- 5 years ago
- Views:
Transcription
1 Allergy and Anaphylaxis Action Plan and Medication Orders Student s Name: D.O.B. Grade: School: Teacher: ALLERGY TO: Place child s photo here To be completed by healthcare provider History: Asthma: YES (Higher risk for severe reaction) NO STEP 1: TREATMENT Any SEVERE SYMPTOMS after suspected or known ingestion: One or more of the following: LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, confused THROAT: Tight, hoarse, trouble breathing/swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body Or combination of symptoms from different body areas: SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) GUT: Vomiting, crampy pain MILD SYMPTOMS ONLY: MOUTH: Itchy mouth SKIN: A few hives around mouth/face, mild itch GUT: Mild nausea/discomfort 1. INJECT EPINEPHRINE IMMEDIATELY 2. Call Begin monitoring (see box below) 4. Give additional medications:* Antihistamine Inhaler (quick relief) if asthma *Antihistamine & quick relief inhalers are not to be depended upon to treat a severe reaction (anaphylaxis). USE EPINEPHRINE 1. GIVE ANTIHISTAMINE 2. Stay with student; alert healthcare professionals and parent 3. If symptoms progress (see above), USE EPINEPHRINE 4. Begin monitoring DOSAGE Epinephrine: inject intramuscularly using autoinjector (check one): 0.3 mg 0.15 mg Administer 2 nd dose if symptoms do not improve in minutes Antihistamine: (brand and dose) If Asthmatic: (brand and dose) Student has been instructed and is capable of carrying and self-administering own medication. Yes No Provider (print) Phone Number: Provider s Signature: Date: If this condition warrants meal accommodations from food service, please complete the medical statement for dietary disability STEP 2: EMERGENCY CALLS 1. If epinephrine given, call 911. State that an allergic reaction has been treated and additional epinephrine, oxygen, or other medications may be needed. 2. Parent: Phone Number: 3. Emergency contacts: Name/Relationship Phone Number(s) a. 1) 2) b. 1) 2) EVEN IF PARENT/GUARDIAN CANNOT BE REACHED; DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Severe Allergy Care Plan for my child. Parent/Guardian s Signature: School Nurse: Date: Date:
2 Student Name: DOB: TRAINED/DELEGATED STAFF MEMBERS 1. Room 2. Room 3. Room 4. Room 5. Room Self-carry contract on file. Yes No Medication located in: EpiPen and EpiPen Jr. Expiration date: Pull off blue activation cap. Auvi-Q 0.3 mg. and 0.15 mg Expiration date: Pull the Auvi-Q from the outer case. Pull off Red safety guard. Place black end against the middle of the outer thigh (through clothing, if needed), then press firmly, and hold in place for 5 seconds. Hold orange tip near outer thigh (through clothing, if needed) Swing and jab firmly into outer thigh until Auto Injector mechanism functions. Hold in place and count to 10. Remove the EpiPen unit and massage the injection area for 10 seconds. Once epinephrine is used, call 911. Student should remain lying down or in a comfortable position. Additional information: C.R.S (3)(b) 2/2013
3 COLORADO SCHOOL ASTHMA CARE PLAN & MEDICATION ORDERS Name: Birth date: Teacher: Grade: Parent/Guardian: Cell Phone: Home Phone: Work Phone: Other Contact: Phone: Preferred Hospital: Triggers: Weather (cold air, wind) Illness Exercise Smoke Dog/Cat Dust Mold Pollen Other: Location of medication: school office student possession at all times other location (list) GREEN ZONE: PRETREATMENT STEPS FOR EXERCISE (Health provider please complete section) Give 2 puffs of quick relief med (name) 15 minutes before activity (Circle indication: Phys Ed class, exercise/sports, recess) Explanation: Repeat in 4 hours if needed for additional or ongoing physical activity YELLOW ZONE: SICK UNCONTROLLED ASTHMA (Health provider complete dosing for quick relief med) IF YOU SEE THIS: DO THIS: Difficulty breathing Wheezing Frequent cough Complains of chest tightness Unable to tolerate regular activities but still talking in complete sentences Other: Stop physical activity Give quick relief med (name): If no improvement in minutes, repeat use of rescue med: If student s symptoms do not improve or worsen, call 911 Stay with student and maintain sitting position Call parents/guardians and school nurse Student may resume normal activities once feeling better If there is no quick relief inhaler at school: Call parents/guardians to pick up student and/or bring inhaler/ medications to school Inform them that if they cannot get to school, 911 may be called RED ZONE: EMERGENCY SITUATION (Health provider complete dosing for quick relief med) IF YOU SEE THIS: Coughs constantly Struggles or gasps for breath Trouble talking (can speak only 3-5 words) Skin of chest and/or neck pull in with breathing Lips or fingernails are gray or blue Level of consciousness DO THIS IMMEDIATELY: Photo of child Give quick relief med (name): Repeat quick relief med if student not improving in minutes Refer to anaphylaxis plan if student has life threatening allergy. Call 911 Inform attendant the reason for the call is asthma Call parents/guardians and school nurse Encourage student to take slower deeper breaths Stay with student and remain calm School personnel should not drive student to hospital INSTRUCTIONS for QUICK RELIEF INHALER USE: (HEALTH PROVIDER: PLEASE CHECK APPROPRIATE BOX(ES) Student understands the proper use of his/her asthma medications, and in my opinion, can carry and use his/her inhaler at school independently Student is to notify his/her designated school health officials after using inhaler. Student needs supervision or assistance to use his/her inhaler. Student has life threatening allergy, refer to anaphylaxis plan. HEALTH CARE PROVIDER SIGNATURE PLEASE PRINT PROVIDER S NAME DATE I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our physician. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Asthma Care Plan for my child. PARENT SIGNATURE DATE 504 Plan or IEP School Nurse Signature DATE Copies of plan provided to: Teachers Phys Ed/Coach Principal Main Office Bus Driver Other CDE Regional Nurse Specialists ( ) June 2011
4 Cherry Creek School District #5 School: Fax #: PERMISSION TO GIVE PRESCRIPTION/HOMEOPATHIC MEDICATION AT SCHOOL The school nurse is required by Colorado State Law to have this form signed by the parents and the Health Care Provider of a student before prescription medication can be administered at school. For safety reasons, parents are requested to bring the medication directly to the nurse. If medication cannot be delivered to the clinic by the parent/guardian, please contact the health clinic to make other arrangements. Prescription meds must be in a pharmacy-labeled container that includes the child s name, medication, dosage, the prescriber s name and directions for administration. Some homeopathic preparations may require a review from the Cherry Creek School District Medical Advisory Board. New forms must be completed with any changes in medication, dose or time to be given. The parent agrees to pick up expired or unused medication within one week of notification or it will be destroyed. To be completed by Licensed Health Care Provider with prescriptive authority: Student s Name: Date of Birth: Medication: Dosage: Route: To be given at the following time(s): Special Instructions: Purpose of medication: Side effects that need to be reported:, including any adverse reaction. Starting Date: Ending Date: (Signature of Health Care Provider with Prescriptive Authority) (License Number) (Print name of Health Care Provider with Prescriptive Authority) (Phone) (Fax) ATTENTION PRESCRIBERS: IF THIS Rx IS FOR A RESCUE INHALER OR EPI-PEN: This student has been instructed by the healthcare provider in the proper use of this medication and is capable of carrying and self-administering this medication. (Signature of Health Care Provider) By signing this document, I give permission for the nurse or nurse designee to administer the medication as prescribed. Should the nurse have any concerns about this order, I give my permission for this Health Care Provider to share information about this medication s administration with the Registered Nurse. (Parent/Guardian Signature) (Phone) (Date) RV This consent must be resubmitted at the beginning of every school year.
5 Seizure Action Plan Effective Date This student is being treated for a seizure disorder. The information below should assist you if a seizure occurs during school hours. Student s Name Date of Birth Parent/Guardian Phone Cell Other Emergency Contact Phone Cell Treating Physician Phone Significant Medical History Seizure Information Seizure Type Length Frequency Description Seizure triggers or warning signs: Student s response after a seizure: Basic First Aid: Care & Comfort Please describe basic first aid procedures: Does student need to leave the classroom after a seizure? Yes No If YES, describe process for returning student to classroom: Emergency Response A seizure emergency for this student is defined as: Seizure Emergency Protocol (Check all that apply and clarify below) Contact school nurse at Call 911 for transport to Notify parent or emergency contact Administer emergency medications as indicated below Notify doctor Other Treatment Protocol During School Hours (include daily and emergency medications) Basic Seizure First Aid Stay calm & track time Keep child safe Do not restrain Do not put anything in mouth Stay with child until fully conscious Record seizure in log For tonic-clonic seizure: Protect head Keep airway open/watch breathing Turn child on side A seizure is generally considered an emergency when: Convulsive (tonic-clonic) seizure lasts longer than 5 minutes Student has repeated seizures without regaining consciousness Student is injured or has diabetes Student has a first-time seizure Student has breathing difficulties Student has a seizure in water Emerg. Dosage & Med. Medication Time of Day Given Common Side Effects & Special Instructions Does student have a Vagus Nerve Stimulator? Yes No If YES, describe magnet use: Special Considerations and Precautions (regarding school activities, sports, trips, etc.) Describe any special considerations or precautions: Physician Signature Date Parent/Guardian Signature Date DPC772 Copyright 2008 Epilepsy Foundation of America, Inc.
FORM CHECKLIST. You must complete online registration at
FORM CHECKLIST You must complete online registration at http://my.cherrycreekschools.org The following optional forms should be brought to Student Check-In on August 2 nd, or returned to the school office
More informationDear Parent/Guardian:
Dear Parent/Guardian: If it is necessary for your child to receive Epinephrine during school hours, school health policy requires that you provide a written request for the administration of the prescribed
More information2.. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours.
STUDENTS August 30, 2012 STUDENTS Health Services Allergic Reactions When a student s physician prescribes emergency allergy injections and related medication (Epinephrine, EpiPen, EpiPen Jr.), and there
More informationSEVERE ALLERGIC REACTION MANAGEMENT PROCEDURE QUESTIONAIRE. Student Name: Current Date: Date of Birth: Grade:
SEVERE ALLERGIC REACTION MANAGEMENT PROCEDURE QUESTIONAIRE Student Name: Current Date: Date of Birth: Grade: 1. Describe in detail what your child is allergic to: 2. How often does your child have a severe
More informationHARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES
HARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES 445 W. Main Street Clarksburg, WV 26301 (304) 326-7690 FAX (304) 326-7691 Dear Parent, Date Please complete the enclosed forms and return them to your
More informationFood / Insect Allergy Action Plan
Food / Insect Allergy Action Plan 2017-2018 Student s Name: of Birth: Teacher Allergy to: Asthmatic: Yes* No Grade *Higher risk for severe reaction Step 1: Treatment Symptoms Give Checked Medication**
More informationHampton Roads Regional Schools Life-Threatening Allergy Management Protocol Forms
Newport News Public Schools Hampton Roads Regional Schools Life-Threatening Allergy Management Protocol Forms Developed by the Hampton Roads School Nurse Managers Parents/Guardians: Please complete Life
More informationRequest for Severe Allergy Information
Request for Severe Allergy Information Dear Parent, You have disclosed that your child has a severe allergy. Wylie ISD requires additional information in order to take necessary precautions for your Child
More informationOgden City School District Allergy Health and Emergency Care Plan for School. School: Grade: School Year:
PARENTS: Please place student s picture here Ogden City School District Allergy Health and Emergency Care Plan for School Student Name: Student must avoid contact with known allergen. School staff must
More informationMedication Administration Skill Checklist (to be accompanied by daily medication log for applicable students) 1 page
See the following pages for exhibits relating to medical treatment: Exhibit A: Exhibit B: Exhibit C: Exhibit D: Exhibit E: Medication Administration Request Form and Guidelines for Administration of Medication
More informationImmunization Requirements as Mandated by the Georgia Department of Public Health
Dear Parents, As we prepare for the upcoming school year, it is time to begin preparing mandatory health forms for the upcoming school year. Our procedures closely align with other private schools in the
More informationLOS ALAMITOS UNIFIED SCHOOL DISTRICT
LOS ALAMITOS UNIFIED SCHOOL DISTRICT Seizure Action Plan Student Name: DOB: School: Grade/Teacher: Parent/Guardian: Phone # Printed Name of Treating Neurologist: Treating Neurologist s Phone # Fax# Seizure
More informationFROM THE DESK OF THE SCHOOL NURSE School Year
FROM THE DESK OF THE SCHOOL NURSE School Year 2016-2107 Dear Parents, Our goal is to provide for the health and well being of your child while s/he is attending school. Please read this letter carefully,
More informationGeneral Use Epinephrine Program Policy and Procedures
General Use Epinephrine Program Policy and Procedures Archdiocese of Baltimore Department of Catholic Schools Office of Risk Management 2016/2017 School Year General Use Epinephrine Program Introduction
More information1 st CONTACT in case of emergency/concern: Relationship: PHONE NUMBERS: Home: Cell: Work:
NORTH DAVIS PREPARATORY ACADEMY (NDPA) STUDENT MEDICAL FORM SCHOOL YEAR: 20 - ID #: ASPIRE: MEDS IN OFFICE: Student s Full Name: Age: Homeroom/Advisory: Grade: Parent/Guardian Full Name: Phone #: Please
More informationMANAGEMENT OF PREVENT AND RESPONSE TO LIFE THREATENING ALLERGIES
File JLDD MANAGEMENT OF PREVENT AND RESPONSE TO LIFE THREATENING ALLERGIES Background The number of students with life-threatening allergies has increased. As with all children with special health care
More informationValparaiso University Student Health Center lmmunotherapy Check List for Allergy patients
Valparaiso University Student Health Center lmmunotherapy Check List for Allergy patients I have read and understood the lmmunotherapy policy and procedure. I have signed the Services Utilization Policy
More informationMANAGEMENT OF PREVENTION AND RESPONSE TO LIFE THREATENING ALLERGIES
File# JLDD MANAGEMENT OF PREVENTION AND RESPONSE TO LIFE THREATENING ALLERGIES Background The number of students with life-threatening allergies has increased. As with all children with special health
More informationSCHOOL DISTRICT #43 (COQUITLAM) MEDICAL ALERT FORMS FORM(S) MUST BE COMPLETED AT THE START OF EACH SCHOOL YEAR
SCHOOL DISTRICT #43 (COQUITLAM) MEDICAL ALERT FORMS FORM(S) MUST BE COMPLETED AT THE START OF EACH SCHOOL YEAR Please read instructions below carefully. Feel free to contact your school if you need any
More informationGlenbrook High School District #225
Glenbrook High School District #225 PROCEDURES FOR IMPLEMENTING BOARD POLICY: FOOD ALLERGY 8235 MANAGEMENT PROGRAM Page 1 of 8 pages Section A - Implementing a Food Allergy Management Program The following
More informationFirst Aid Policy for pupils
First Aid Policy for pupils Introduction At Old Church Primary we recognise the importance of providing adequate and appropriate First Aid equipment and facilities for all children and will take all reasonable
More informationPOLICY TITLE: Administering Medications POLICY NO: 561 PAGE 1 of 5 MEDICATIONS
POLICY TITLE: Administering Medications POLICY NO: 561 PAGE 1 of 5 MEDICATIONS The Board of Trustees of the Mountain Home School District recognizes that students attending the schools in this district
More informationWynne Public Schools P.O. Box 69 Wynne, Arkansas Seizure Care In The School
Date_ Student_ Dear Parent/Guardian, Wynne Public Schools P.O. Box 69 Wynne, Arkansas 72396 Seizure Care In The School Grade Our records indicate that your child has a seizure disorder; good management
More informationGlastonbury Family YMCA. CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET
2018 Glastonbury Family YMCA CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET CAMP LOCATION 30 High Street South Glastonbury, CT 06073 860-541-1812 STEP STEP one REGISTRATION Done online,
More informationPage 17. Medication Management Policy and Practice Guidelines
Page 17 APPENDIX A Medication Management Policy and Practice Guidelines Index Scope Definition of medication Principles underpinning safe use of medications Procedure Guidelines Scope 1. Medication packaging
More informationNEBO SCHOOL DISTRICT BOARD OF EDUCATION POLICIES AND PROCEDURES
NEBO SCHOOL DISTRICT BOARD OF EDUCATION POLICIES AND PROCEDURES J - Students Administering Medication to Students JHCD DATED: August 8, 2018 SECTION: POLICY TITLE: FILE NO.: TABLE OF CONTENTS 1. PURPOSE
More informationPGD5417. Clinical Performance Director of Nursing Allison Bussey
PGD5417 Patient Group Direction Administration of Adrenaline (Epinephrine) 1:1000 (1mg/ml) Injection By Registered Nurses and Midwives employed by South Staffordshire & Shropshire Healthcare Foundation
More informationADMINISTRATION OF MEDICATION BY DELEGATION
ADMINISTRATION OF MEDICATION BY DELEGATION ROLE AND RESPONSIBILITY OF THE TEACHER TRAINING MANUAL Medication Training Manual Final 10-2-17 Page 1 of 17 MEDICATION ADMINISTRATION TRAINING OBJECTIVES UPON
More informationHealth Authority Abu Dhabi
Health Authority Abu Dhabi Document Title: HAAD Standards for administration of medication in schools Document Ref. Number: HAAD/AMDS/SD/1.0 Version 1.0 Approval Date: 13 August 2012 Effective Date: August
More informationThis policy is designed to assist in the maintenance of the health, safety and wellbeing of all students at the College.
FIRST AID POLICY (First Aid, Asthma, Anaphylaxis, Ambulance Attendance) Introduction This policy is designed to assist in the maintenance of the health, safety and wellbeing of all students at the College.
More information- B - CARE OF SICK OR INJURED STUDENTS
- B - CARE OF SICK OR INJURED STUDENTS Authorization for Emergency Care Each school should maintain for emergency reference, an updated Emergency Contact Information and Authorization for Release Form
More informationSTUDENTS Any school employee authorized in writing by the school administrator or school principal:
Fremont School District No. 215 STUDENTS 3510 Student Medicines Assistance in Self Administration of Medicines to Students Any school employee authorized in writing by the school administrator or school
More informationHEALTH PACKET. EPI-PEN, ASTHMA and ALLERGY
HEALTH PACKET EPI-PEN, ASTHMA and ALLERGY Epi-Pen and/or Inhaler Agreement Child s Name: Class: Name of Medication (s): Yes No I authorize the school nurse/director to contact my physician with any questions
More informationSUBJECT: STUDENTS WITH LIFE-THREATENING HEALTH CONDITIONS
1 of 6 come to school with diverse medical conditions which may impact their learning as well as their health. Some of these conditions are serious and may be life-threatening., parents, school personnel
More informationAIR FORCE CHILD AND YOUTH PROGRAMS MEDICATION ADMINISTRATION INSTRUCTIONAL GUIDE
AIR FORCE CHILD AND YOUTH PROGRAMS MEDICATION ADMINISTRATION INSTRUCTIONAL GUIDE September 2013 1. TRAINING OBJECTIVE: To assist CYP personnel (CYP staff and Family Child Care (FCC) providers) in understanding
More informationMedication Policy. Linked to National Quality Standards- Quality Area Two: Element Policy statement
Medication Policy Administering medication should be considered a high risk practice. Authority must be obtained from a parent or legal guardian before educators administer any medication (prescribed or
More informationPolicy Title: Administration of Medication by School Personnel Policy No:
Policy Title: Administration of Medication by School Personnel Policy No: 504.14 The Board of Trustees recognizes that students attending schools in St. Maries Joint School District No. 41 may be required
More information2. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours.
STUDENTS June 4, 2014 STUDENTS Health Services Allergic Reactions When a student s physician prescribes emergency allergy injections and related medication (Epinephrine Auto-Injection), and there is the
More informationMcMinnville School District #40
McMinnville School District #40 Code: JHCD/JHCDA-AR Adopted: 1/08 Revised/Readopted: 8/10; 2/14; 2/15 Orig. Code: JHCD/JHCDA-AR Prescription/Nonprescription Medication Students may, subject to the provisions
More informationCygnet Schools. First Aid Policy
Cygnet Schools First Aid Policy Table 1 Related Policies CARDIAC ARREST (CP 12) DFE GUIDANCE ON SUPPORTING PUPILS WITH MEDICAL CONDITIONS (2014) GUIDANCE ON FIRST AID IN SCHOOLS (2014) HEALTH AND SAFETY
More informationREQUEST FOR SELF-ADMINSTRATION OF MEDICATION AT SCHOOL (Only for Epi-Pen and Metered Dose Inhaler) School: Teacher: Grade:
REQUEST FOR SELF-ADMINSTRATION OF MEDICATION AT SCHOOL (Only for Epi-Pen and Metered Dose Inhaler) Student: Birth Date: School: Teacher: Grade: TO BE COMPLETED BY AUTHORIZED HEALTH CARE PROVIDER Medication
More informationAnaphylactic Reaction Emergency Treatment Reference Number:
This is an official Northern Trust policy and should not be edited in any way Anaphylactic Reaction Emergency Treatment Reference Number: NHSCT/12/551 Target audience: Nursing Staff Groups included are:
More informationPolicies and Procedures. Number: 1243
Policies and Procedures Title: ANAPHYLAXIS - INITIAL MANAGEMENT RNSP: RN Clinical Protocol: Health Condition in an Emergency Number: 1243 Authorization: [X] SHR Nursing Practice Committee Source: Nursing
More informationRaleigh Parks and Recreation. Permission Form for Assisted Administration of Medication
Raleigh Parks and Recreation Permission Form for Assisted Administration of Medication Parks and Recreation employees only administer medication to participants if: 1. The City of Raleigh Permission Form
More informationAlso, you must acknowledge that you understand the following by signing and dating this sheet:
To the parents of You have registered a child for one of our programs and indicated that he or she has a documented life threatening food or insect allergy or other severe allergic reaction that requires
More information1.1 To provide guidelines for medication administration to students while at school.
Windsor-Essex Catholic District School Board NUMBER: Pr ST: 11 Section: Students PROCEDURE Pr ST: 11 Student Health Support (Including Medication Administration at School) EFFECTIVE: Oct. 26, 1999 AMENDED:
More informationPARENT PACKET - SEIZURE
School Year: Model Laboratory School SCHOOL HEALTH DIVISION (859) (859) PARENT PACKET - SEIZURE Dear Parent/Guardian: You have informed us that your student has a medical concern. Enclosed are the forms,
More informationLife Threatening Allergies Natick Public Schools
Life Threatening Allergies Natick Public Schools Anaphylaxis Background: Anaphylaxis is a sudden, severe, potentially fatal, systemic allergic reaction (LTA), that can involve various body systems, such
More informationADMINISTRATION OF MEDICATION PROCEDURE
1302.47 Safety practices. ADMINISTRATION OF MEDICATION PROCEDURE b) A program must develop and implement a system of management, including ongoing training, oversight, correction and continuous improvement
More informationMedication Administration in School
Medication Administration in School The parent/guardian of (Child s name) ask that the school nurse administer or principal/principal s designee observe selfadministration of the following medicine(s):
More informationGuidelines on Medication Administration for School Personnel
2017 Guidelines on Medication Administration for School Personnel ACKNOWLEDGMENTS Utah Department of Health Environment, Policy, and Improved Clinical Care (EPICC) Utah School Nurse Consultant Elizabeth
More informationThe Holt School Medical Conditions Policy.
The Holt School Medical Conditions Policy. September 2014 This document is statement of the aims, principles and strategies for ensuring the health and safety of students with medical needs at The Holt
More informationSTUDENTS 3416 page 1 of 4 Administering Medicines to Students
0 1 0 1 Livingston School District STUDENTS page 1 of Administering Medicines to Students Medication means prescribed drugs and medical devices that are controlled by the U.S. Food and Drug Administration
More informationMedical Conditions Policy
Medical Conditions Policy Date: Summer 2016 Revision Date: Summer 2017 Medical Conditions Policy Introduction Goose Green Primary and Nursery School ( Goose Green ) is a mainstream state-funded academy
More information4.35 STUDENT MEDICATIONS
4.35 STUDENT MEDICATIONS General Authority of School Nurses Regarding Student Medications School nurses are not permitted to diagnose medical conditions or prescribe medications, including over-thecounter
More information2. Short term prescription medication and drugs (administered for less than two weeks):
Medication Administration Procedure This is a companion document with Policy # 516 Student Medication To access the policy: click on Policies (under the District Information heading) The Licensed School
More informationThe School Nurse team hold annual EPIPEN training for staff and the Diabetic team train staff on the treatment of individual pupils as necessary.
Malbank School and Sixth Form College Medical Needs and Administration of Medication Policy. Some students have a history of medical problems. In most cases pupils will be able to attend school and participate
More informationStudent/School Health Services SP 6.129
POLICIES & PROCEDURES LAST REVISED: September 2017 (See revision history on last page.) Administration of Medication and /or Assisting with the Self-Administration of Medications As required by the State
More informationWITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you
PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
More informationLIBERTY PUBLIC SCHOOL DISTRICT FOOD ALLERGY POLICY & GUIDELINES
] LIBERTY PUBLIC SCHOOL DISTRICT FOOD ALLERGY POLICY & GUIDELINES Allergy Management Policy Board Policy JHC Liberty Public Schools is committed to providing a safe and nurturing environment for students.
More informationI acknowledge that during camp my child / ward may be taken swimming and I give my permission to do so.
Student Consent Form Camp Agreement I agree to my child s / ward s attendance at the below mentioned program Hunter Christian School Yr.8 Outdoor Education Program 5-7 March 2018 As parent / guardian I
More informationSUPPORTING CHILDREN AND STUDENTS WITH PREVALENT MEDICAL CONDITIONS ASTHMA ENSURING ASTHMA FRIENDLY SCHOOLS RYAN S LAW POLICY CODE: J 5.
POLICY CODE: J 5.11 Policy Statement: The support of students with prevalent medical conditions is complex requiring a whole-school approach to promote student health and safety and to foster and maintain
More informationADMINISTRATIVE PROCEDURES
Batch #4, Redline Edits SHELTON SCHOOL DISTRICT ADMINISTRATIVE PROCEDURES Policy No. 3416P Series 3000 (Students) Page 1 of 8 PROCEDURE - MEDICATION AT SCHOOL Under normal circumstances prescribed or oral
More information*A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR TO ADMITTANCE*
WASHINGTON ACADEMY STUDENT HEALTH INFORMATION PACKET SCHOOL NURSE: PHONE: 973-239-6555 Ext: 204 FAX: 973-239-6335 *A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR
More informationRETURNING Student Information Update
Today s Date: RETURNING Student Information Update OFFICE USE ONLY School # Student # Grade Level Teacher Student Legal Name (first, middle, last) Suffix (Jr., Sr., II, lii, IV, V) Student Date of Birth
More informationGuidelines for Medication Distribution
STUDENTS Guidelines for Medication Distribution 09.2241 AP.1 STUDENT SELF-MEDICATION With the written permission of a licensed healthcare provider and approval by the Principal, students may be authorized
More informationSTUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016
STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 The Clinic The Howard School 1192 Foster Street, NW Atlanta, Georgia 30318 Please complete this form and return with the other enrollment forms. Student
More informationAllergy and Anaphylaxis Policy
The Hertfordshire & Essex High School Title Allergy and Anaphylaxis Supporting Students with Medical Conditions Version Version 1/2016 Author Sally House: Assistant Head 2016 Committee Responsible Date
More informationScott County Public School District
Scott County Public School District Medication Administration Training for School Personnel Prepared by: Rachel Burke, RN School Nurse Coordinator 1-276-386-6515 rachel.burke@scottschools.com Healthy Kids
More informationDealing with Medical Conditions
SAMPLE POLICY Dealing with Policy Statement This policy acts to ensure that: Children are supported to feel physically and emotionally well, and feel safe in the knowledge that their wellbeing and individual
More informationSt Mary s Church of England Primary School. First Aid Policy
St Mary s Church of England Primary School First Aid Policy 1. Aims To act safely, promptly and effectively with accidents and emergencies To use basic first aid equipment To maintain records on the nature
More informationOur Lady and St Bede Catholic Academy School FIRST AID POLICY
Our Lady and St Bede Catholic Academy School FIRST AID POLICY Document Management: Date Policy Approved: October 2009 Date reviewed: October 2018 Next Review Date: June 2021 Version: 2.0 Approving Body:
More informationST BEDE S CATHOLIC ACADEMY FIRST AID POLICY
ST BEDE S CATHOLIC ACADEMY FIRST AID POLICY Document Management: Date Policy Approved: October 2009 Date reviewed: September 2018 Next Review Date: September 2021 Version: 2.0 Approving Body: Local Management
More informationTable of Contents. I. Introduction 1. II. Overview of Life-threatening Allergies & Anaphylaxis 2-4
March 2015 Table of Contents SECTION PAGE (S) I. Introduction 1 II. Overview of Life-threatening Allergies & Anaphylaxis 2-4 III. Plans to Accommodate Students with Life-Threatening Allergies 4-5 A. Emergency
More informationCAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018
1 CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018 CHECK LIST & INSTRUCTIONS FOR COMPLETING THIS FORM: This Medical Form is required EACH YEAR for every participant of Camp Wastahi. As a requirement
More informationManagement of Students with Food Anaphylaxis - Procedural Manual
Management of Students with Food Anaphylaxis - Procedural Manual w w w. w a s h o e s c h o o l s. n e t 7 7 5. 3 4 8. 0 2 0 0 4 2 5 E a s t N i n t h S t r e e t R e n o, N V 8 9 5 1 2 Non-Discrimination
More informationWest Hartford YMCA CHILD CARE Registration Packet School Year
West Hartford YMCA CHILD CARE Registration Packet 2017-2018 School Year Dear YMCA Family, For Youth Development, For Healthy Living, For Social Responsibility Thank you for choosing the West Hartford YMCA
More informationStudent Health Care Anaphylaxis, Communicable Disease and Pandemic Management Policy
SILVER TREE STEINER SCHOOL Student Health Care Anaphylaxis, Communicable Disease and Pandemic Management Policy 2016 This policy applies to: The Administrator, teaching staff and non-teaching staff. AUTHORISED
More informationThe first or adjusted dose of medication shall be administered at home by the parent/guardian prior to delivery of medication to school/sacc.
Regulation 757-4 August 30, 2012 Administering Medication I. It is the intent of the Prince William County Public Schools (PWCS) to assist parents/guardians when they are unable to come to school/school
More informationSchool Committee Policy on Life Threatening Allergies (Revised Policy Approved on June 17, 2015)
School Committee Policy on Life Threatening Allergies (Revised Policy Approved on June 17, 2015) Background: Allergic reactions span a wide range in the severity of symptoms. The most severe and life threatening
More informationRegulation of the Chancellor
Regulation of the Chancellor Category: STUDENTS Issued: Number: A-715 Subject: ADMINISTRATION OF EPINEPHRINE TO STUDENTS WITH SEVERE Page: 1 of 1 SUMMARY OF CHANGES This regulation supersedes Chancellor
More informationOverview of Allergic Reactions
PROTOCOL AND GUIDELINES FOR STUDENTS WITH LIFE- THREATENING ALLERGIES (LTAs) IN THE ST. JOSEPH PUBLIC SCHOOLS Overview of Allergic Reactions Allergic reactions can span a wide range of symptoms and severity.
More informationProcedure No. 3420P Anaphylaxis Prevention and Response Controlling the Exposure to Allergens
Anaphylaxis Prevention and Response For students with a medically diagnosed life threatening allergy (anaphylaxis), which requires an epinephrine prescription, the district will take appropriate steps
More informationSchool, Support Service & Sports College FIRST AID POLICY
Round Oak School, Support Service & Sports College FIRST AID POLICY Reviewed: Next Review: Signed Jane Naylor Head Teacher Date.. Signed Val Mobberley Chair of Governors Date.. "Round Oak School is a good
More informationMANAGING STUDENTS MEDICATIONS AND EMERGENCY MEDICAL NEEDS NEPN Code: JLCD
MANAGING STUDENTS MEDICATIONS AND EMERGENCY MEDICAL NEEDS Authorization Forms for Parents and Physicians: JLCD-E (1) JLCD-E (1a) JLCD-E (2) JLCD-E (2a) JLCD-E (3) JLCD-E (4) JLCD-E (4a) JLCD-E (4b) Authorization
More informationBYRCHALL HIGH SCHOOL. First Aid Policy. (Including Administering Medicines to Children and Young People at Byrchall High School)
BYRCHALL HIGH SCHOOL First Aid Policy (Including Administering Medicines to Children and Young People at Byrchall High School) Date Signed Date Reviewed March 2018 Ratified by Governors Date of next Review
More informationAllergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease
Allergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease Arthur Fost, M.D. David Fost, M.D. Satya Narisety, M.D. Anthony J. Piccolo, PA-C Patient s Name
More informationMEDICAL CONDITIONS POLICY
MEDICAL CONDITIONS POLICY Purpose Clear procedures are required to support the health, wellbeing and inclusion of all children enrolled at the service. Our service practices support the enrolment of children
More informationMedical Conditions Policy
Medical Conditions Policy This policy was approved and ratified by Peoples Committee of Cox Green School On 15 th November 2016 Version Authorisation Approval Date Effective Date Next Review 1 Full Governing
More information2015 CPR / Resuscitation Skills EMERGENCY MEDICAL SERVICES
2015 CPR / Resuscitation Skills EMERGENCY MEDICAL SERVICES SKILL CHECKLIST Cardiac Arrest NAME PRINT NAME EMS # DATE Objective: Given a multi-person company, BLS/ALS equipment and manikin: demonstrate
More informationFIRST AID AND MEDICAL POLICY AND PROCEDURES
FIRST AID AND MEDICAL POLICY AND PROCEDURES FIRST AID AND MEDICAL POLICY Drafted By: Education Manager& First Aid Admin Status: CURRENT Responsibility: Management Team Scheduled review Date: April 2017
More informationScope These guidelines apply to all St Thomas the Apostle staff members and contractors whilst performing duties on behalf of the school.
First Aid Guidelines Introduction St Thomas the Apostle Primary School is committed to providing an effective system of first aid management to respond immediately and protect the health, safety and welfare
More informationtimes and/or the specific situations in which it is to be prescription number taken
PROCEDURES FOR REQUESTING EMERGENCY TREATMENT FOR CHILDREN WITH ALLERGIES/ANAPHYLAXIS REQUIRING The City of Poway ( City ) recognizes that some children may have allergies of such severity that they may
More informationTOPS Piano and Creative Writing Camp Registration Form Summer 2018
TOPS Piano and Creative Writing Camp Registration Form Summer 2018 Returning Camper New Camper Camper s Name Email(s) Address City Zip code Home phone Work phone(s) Cell phone(s) Parent/Guardian name Please
More informationPatient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
More informationHawaiian Fun: At Greene County 4-H Camp
OHIO STATE UNIVERSITY EXTENSION Hawaiian Fun: At Greene County 4-H Camp Greene County 4-H Camp Registration Due: Friday, May 12, 2017 4-H Camp Dates: June 14-18 Camper Name Are you a 4-H member? Yes or
More informationAmbassador Program Application Packet
Ambassador Program Application Packet Thank you for your interest in becoming an Ambassador at Centinela Hospital Medical Center. Please complete the attached forms and then contact the Centinela Hospital
More informationSafe Care for Michigan Kids
Safe Care for Michigan Kids HEALTHY KIDS ARE BETTER LEARNERS Safe Care for Michigan Kids EVILIA JANKOWSKI, MSA, RN, BSN PRESIDENT MICHIGAN ASSOCIATION OF SCHOOL NURSES Objectives To communicate the significance
More informationStratford Board of Education
POLICY STATEMENT FOR ADMINISTRATION OF MEDICATIONS BY SCHOOL PERSONNEL It is the policy of the Stratford Board of Education to be in conformity with Section 10 212a 1 to 10 212a 7, as revised of the General
More informationInformation Needed for Registration
Information Needed for Registration Prospective Kindergarten students must be five years old by September 30, 2017. Prospective Pre-Kindergarten students must be four years old by September 30, 2017. All
More information