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 of your child s condition is important for success at school. If your child requires emergency medication, please complete the attached packet. Return the clearly labeled medication(s) and any needed supplies to school. If your child does not require the use of emergency medication for seizures, please sign and return this form. Content of packet to be completed and returned to school nurse if emergency medication is needed. 1. Medication Administration Consent Form- Parent signs 2. Consent to Communicate with child s doctor- Parent signs 3. Seizure Action Plan-Doctor completes, Parent signs MY child ONLY has a history of Seizures and no longer takes medications. My child still takes daily seizure medication at home, but does not require emergency medications. Parent/Guardian: Date:_ If you have any questions, please call me at the number below. Your doctor may fax completed, signed forms to the school. Thank you, School Nurse District Primary Intermediate Jr. High Sr. High Jill Davis, RN Erin Oguin,RN Ashley Duncan,RN Rebecca Strasser, RN Carol Woodruff, RN (870) 238-5030 238-5050 ext 0353 238-5060 ext. 0329 238-5040 ext. 0272 238-5070 ext. 0229 Fax (870)238-5053 Fax (870)238-5063 Fax (870)238-5043 Fax (870)238-5009
SEIZURE ACTION PLAN FOR SCHOOL Student Name D.O.B. ID # Student School Teacher Picture Physician Phone: EMERGENCY CONTACTS Name Relationship Home # Work # Cell # 1. 2. 3. Type of seizure: What does the seizure look like and how long does it usually last? Possible triggers that should be avoided: Does student need any special activity adaptations/protective equipment (e.g., helmet) at school? _ No _ Yes (explain) Is student allowed to participate in physical education and other activities? _ No _ Yes (explain) ARE MEDICATIONS NEEDED TO CONTROL THE SEIZURES? _ No _ Yes (List below the medications needed) MEDICATIONS AMOUNT TAKEN HOW OFTEN AND FOR WHAT SIGNS 1. 2. 3. List medication needed at school (name, dosage/route, and frequency) Possible side effects that must be reported to parent or physician: IF GENERALIZED SEIZURE OCCURS: 1. If falling, assist student to floor, turn to side. 2. Loosen clothing at neck and waist; protect head from injury. 3. Clear away furniture and other objects from area. 4. Have another classroom adult direct students away from area. 5. TIME THE SEIZURE. 6. Allow seizure to run its course; DO NOT restrain or insert anything into student s mouth. Do not try to stop purposeless behavior. 7. During a general or grand mal seizure expect to see pale or bluish discoloration of the skin or lips. Expect to hear noisy breathing.
IF SMALLER SEIZURE OCCURS (e.g., lip smacking, behavior outburst, staring, twitching of mouth or hands) 1. Assist student to comfortable, sitting position. 2. Time the seizure. 3. Stay with student, speak gently, and help student get back on task following seizure. IF STUDENT EXHIBITS: 1. Absence of breathing or pulse. 2. Seizure of 10 minutes or greater duration. 3. Two or more consecutive (without a period of consciousness between) seizures which total 10 minutes or greater. 4. Continued unusually pale or bluish skin or lips or noisy breathing after the seizure has stopped. INTERVENTION: 1. Call 911. 2. START CPR for absent breathing or pulse. WHEN SEIZURE COMPLETED: 1. Reorient and assure student. a. Assist change into clean clothing if necessary. b. Allow student to sleep, as desired, after seizure. c. Allow student to eat, as desired, once fully alert and oriented. 2. A student recovering from a generalized seizure may manifest abnormal behavior such as incoherent speech, extreme restlessness, and confusion. This may last from five minutes to hours. 3. Inform parent immediately of seizure via telephone conversation if: a. Seizure is different from usual type or frequency or has not occurred at school in past month. b. Seizure meets criteria for 911 emergency call. c. Student has not returned to "normal self" after 30-60 minutes. 4. Record seizure on Seizure Activity Log. If you want additional care given, describe action here: If symptoms are Give_ (medication/dose/route) Possible side effects_ Physician Signature Date Print Name Phone I want this plan implemented for my child,, in school. I hereby give my permission for exchange of confidential information contained in the record of my child between the nurse and physician and my signature is an informed consent to share this medical information with school staff as a need to know for academic success and emergency plan as determined by the nurse. Parent/Guardian Signature: Approved by School Nurse School Nurse Signature: Date: Date:
STUDENTS WITH SPECIAL HEALTH CARE NEEDS EMERGENCY PLAN NON-MEDICAL STAFF STUDENT NAME : DOB: TEACHER: RM/GRADE :_ PARENT/GUARDIAN: PREFERRED HOSPITAL: HOME PHONE #: WORK #: CELL #:_ EMERGENCY CONTACT: PHONE: OTHER PHONE:_ PHYSICIAN: PHYSICIAN TEL: PHYSICIAN FAX: STUDENT-SPECIFIC EMERGENCIES IF YOU SEE THIS DO THIS IF AN EMERGENCY OCCURS: 1. If the emergency is life-threatening, immediately call 911. 2. Stay with student or designate another adult to do so. 3. Call or designate someone to call the principal and/or school nurse. a. State who you are. b. State where you are. c. State problem. DOCUMENTATION OF STAFF TRAINING DATE: TRAINED BY: STAFF NAME:
STUDENTS TRANSPORTED WITH SPECIAL EQUIPMENT/NEEDS DRIVER/ATTENDANT INFORMATION SHEET STUDENT NAME : ADDRESS:_ PARENT/GUARDIAN: SCHOOL: TEACHER: AM ROUTE:PM ROUTE: HOME PHONE #: WORK #: CELL #:_ EMERGENCY CONTACT: PHONE: OTHER PHONE:_ PHYSICIAN: PHYSICIAN TEL: PHYSICIAN FAX: SPECIAL EQUIPMENT OR MEDICAL NEEDS ON BUS I.E. OXYGEN TANK, WHEELCHAIR, SEIZURES, GO-BAGS, ETC.- PLEASE INCLUDE SIZE AND DIMENSIONS OF ALL EQUIPMENT EMERGENCY BUS PLAN IF YOU SEE THIS DO THIS BEHAVIOR PLAN BEHAVIOR OR DISABILITY: INTERVENTION TO MANAGE THE BEHAVIOR/DISABILITY OTHER SPECIFIC NEEDS FOR SAFELY TRANSPORTING STUDENT DOCUMENTATION OF DRIVER/ATTENDANT TRAINING DATE DRIVER/ATTENDANT NAME NURSE/SCHOOL OFFICIAL
Wynne Public Schools P.O. Box 69 Wynne, Arkansas 72396 Consent To Share Information Student s Name Student s Date of Birth Student s School ID#_ I authorize personnel of the Wynne School District and personnel with any relevant agency or provider to access and exchange information in my or my child s files that may be beneficial in providing any or all needed services. I understand that I am giving my permission to share confidential information in an effort to better serve the needs of my family. Print Name of Parent/Legal Guardian Date Signature of Parent/Legal Guardian Date Nurse Signature Date
Wynne Public Schools P.O. Box 69 Wynne, Arkansas 72396 Medication Administration Consent Form Student Name DOB_Grade_HmRm Name of Medication Dosage_ Time to be Taken Ordering Physician Reason for Medication Other instructions Medication Procedures: 1. Only medications that are ordered and labeled to be taken with meals, at a specified time during school hours, or 4 or more times a day will be administered at school. Morning doses should be taken at home with a snack prior to coming to school. 2. Parent/guardian/designated adult must bring/sign in/count all medications, prescription and/or over-the-counter (OTC), to the nurse s office. Students are NOT permitted to have medication in their possession on the school bus or school campuses. EXCEPTION: EMERGENCY medications if consents/doctor orders are on file in nurse s office; these must be renewed annually. 3. All medications must be in the original container with the student s prescription label in place. OTC medications should have the student s name written on it and have the manufacturer s dose and directions included. I certify that at least one dose of this medication has previously been given (exception: emergency medication) with NO adverse reactions. Therefore, I give permission for the school to administer the above medication to my child according to the Board of Education procedure (see above). I will not hold the school staff responsible for any undesired reaction or effects which may occur from the medication. Only emergency medications will be sent on off-campus activities. I give permission for the school nurse to contact the prescribing doctor about medication(s) and to take a photograph of my child for identity purposes. Signature of Parent/Guardian Date Contact Number_
A.C.A. 6-18-707, Act 1694, 20-13-401-7 Rev 08/2011 Wynne Public Schools P.O. Box 69 Wynne, Arkansas 72396 EMERGENCY MEDICATION SELF-ADMINISTRATION CONSENT FORM P.O.BOX 69 * WYNNE, ARKANSAS * 72396 Primary 238-5050, Intermediate 238-5060, Jr. High 238-5040, High School 238-5070 Student Name: Birth date: Parent/Guardian(print) Physician Name: Medication: Reason: (PRINT) (PRINT) The following MUST BE PROVIDED to the school by the parent/guardian to the school before the student will be allowed to carry and use emergency medication while at school, at an on-site school-sponsored activity, or at an off-campus school-sponsored activity. This is only valid for this academic school year at Wynne Schools. A new plan and consent must be obtained each school year or any re-entry into the Wynne Schools: PHYSICIAN -- As the prescribing physician, please verify the following for the above named student: _ Diagnosis(es): Name of medicine: Rx: Rx: Student needs emergency medication while at school, including any school-sponsored activity, due to a medical condition. _ Student CAN demonstrate the skill level, understands the treatment plan, has the responsibility necessary to use and selfadminister the prescribed medication _ I DO NOT RECOMMEND THAT THIS STUDENT CARRY OR SELF-ADMINISTER THIS EMERGENCY MEDICATION. Physician signature: Phone numbers: Date: PARENT -- As the parent/guardian of the above name student: _ I have discussed and agree with the treatment plan set up by the prescribing physician. _ I give permission for my child to carry and use emergency medicine while at school, at an on-site school-sponsored activity, or at an off-campus school-sponsored activity including any off-campus school activity. _ I agree and understand the school s student contract/agreement which my child has signed. _ I understand that I will supply my child s self-administered medicine, that it must have a current prescription label attached and be stored & transported in its original prescription-labeled container inside the student s backpack or purse. _ I understand my child must not share, transfer, unpack, show to others, or in any way divert their emergency medicine to any other student or person or shall be subject to disciplinary measures according to the school board of education policies for drug abuse. _ I understand that if my child does not demonstrate reliable behavior while carrying his/her emergency medicine, he/she will lose this privilege and the medication will be kept in the school Health Office. _ I will notify the school nurse or principal of any changes in the student s condition, medication or dosage, or changes in emergency contact information. No school employee, school agent, or school district shall be held liable for injury to a student caused by his/her use of self-administered medication. Parent/Guardian signature: Phone numbers: Date: STUDENT -- As the student, my responsibilities include: _ I understand the treatment plan documented by my prescribing physician. _ I can state when I need to use my emergency medication as documented by my doctor. _ I have demonstrated the skill necessary to use and self-administer my emergency medicine.
A.C.A. 6-18-707, Act 1694, 20-13-401-7 Rev 08/2011 _ I will immediately report to the school nurse (or designee) or principal, when I use my emergency medications so that my emergency emergency plan can be put into effect. _ I will carry my emergency medicine inside my backpack or purse in its original prescription-labeled container and will only take it out to self administer the medication during an emergency. _ I will not share, transfer, unpack, show to others, or in any way divert my emergency medicine to any other student or person, I shall be subject to disciplinary measures according to the school board of education policies for drug abuse. _ I understand that if I do not demonstrate reliable behavior while carrying my emergency medicine, I will lose this privilege and the medication will be kept in the school Health Office. Student signature: Phone number Date NURSE -- _ Received Emergency Action Plan from student s physician with MD signature. _ Physician signed MD section of this form. _ Student can demonstrate the skill level and verbalizes understanding of the treatment plan and correct administering procedure. _ Student signed above contract and verbalizes understanding. _ Signature completed in Parent section of this form and verbalizes understanding. _ Parent completed and signed authorization to release information form. _ Parent signed Medication Administration Consents. _ Student cannot demonstrate the skill level or verbalize understanding of the treatment plan and correct administering procedure (explain below).. Additional Comments: Nurse signature: Date: