Individualized Health Care Plans

Parents/guardians are to notify the school if their student has any medical conditions that may affect his/her ability to learn,(  e.g., Diabetes, Seizures, Asthma, Severe Allergies, etc.) This will allow the Credentialed School Nurse to develop a plan to provide appropriate care in an emergency.  The Credentialed School Nurse will develop an individualized health care plan for the student.  The student’s safety and health is always a top priority.  Emergency action plans are developed based upon conditions reported by parents/guardians.  For more information, please contact Lois Schultz-Grant RN, MS.

Condition Note from Nurse
See Below
Forms
Please Print and Take to Physician
 Asthma  Please See Below  Permission to Carry Medication

Diabetes  Please See Below  Authorization Physician Form for Diabetes
Permission to Carry Medication
Seizure History Please See Below 

Standard Seizure Protocol
 Seizure Information Sheet
Severe Allergies/ Anaphylaxis (EPI Pen)

 Please See Below  Permission to Carry Medication
 Medication During School Hours

 Please See Below  Doctor's Order for Medication During School Hours


The District Nurse has provided the following Notes from the Nurse regarding Asthma, Diabetes, Seizures, Severe Allergic Reactions and Medication During the Day

Asthma:  If you have indicated that your child has a history of Asthma.  To help your child succeed, please fill out the “Permission to Carry Medication form” and clearly indicate which triggers may cause an asthma episode. Please return the form to your Child’s HOME SCHOOL.  

Diabetes:  If you have indicated that your child has a history of Diabetes.  Please print out the Authorization from Physician form and have your child and physician complete it.  Both you and your physician must sign this form.  Also, please fill out the permission to Carry Medications which will allow your child to carry his insulin kit on his person.  Once we have received these forms, the Credentialed School Nurse will complete an emergency plan (with input from your child) and make certain that each of your child’s teachers knows what to do to help in the event of an emergency. Please return the forms to your Child’s HOME SCHOOL.

Seizure History:  If you have indicated that your child has a history of Seizures.  Please review the “Standard Seizure Protocol”.  This is the plan that is used by the school for anyone who has a Generalized Clonic/Tonic Seizure.  Also, please complete the Seizure Information Form.  This will be reviewed by the Credentialed School Nurse to assess if additional emergency protocols are needed.  Please return the form to your child’s HOME SCHOOL.  

Severe Allergic Reaction/EPIPEN Auto Injectors:  If you have indicated that your child has a severe Allergy that necessitates the need to carry and Epinephrine Auto Injector (EPI PEN), please fill out the permission to carry medication form.  Please make sure to indicate what your child is allergic to.  Also, please indicate if your child should also carry Benadryl or other Antihistamines.  Once the school receives this form, the Credentialed School Nurse  (working with your child) will develop  an Emergency Plan to be put into effect if your child needs to use his/her EPI PEN.  This plan will be given to your child’s teacher.  Please return the form to your child;s HOME SCHOOL.  

Medication During the School Day: If you have indicated that your child requires medication during the school day, including Over the Counter Medications (i.e. Tylenol, Advil, or other medications not usually requiring a physician order) please note that, for your child to receive these medications during school hours the Medication Authorization form must be completed and signed by a physician and parent/guardian.  Medications must be in a pharmacy labeled bottle.  Upon receipt of this form and the medication, trained staff members will help your child receive the medication ordered in an appropriate manner.  


Condition Letter From Nurse: Please Read

Forms required:please print and take to physician

Asthma Note from Nurse Permission to Carry Medication

Diabetes

Note from Nurse

Authorization Physician Form for Diabetes

Permission to Carry Medication

Seizure History

Note from Nurse

Standard Seizure Protocol

Seizure Information Sheet

Severe Allergies/Anaphylaxis (EPI Pen)

Note from Nurse

Permission to Carry Medication

Medication Administration During School Hours Note from Nurse Doctor's Order for Medication During School Hours

Condition Letter From Nurse: Please Read

Forms required:please print and take to physician

Asthma Note from Nurse Permission to Carry Medication

Diabetes

Note from Nurse

Authorization Physician Form for Diabetes

Permission to Carry Medication

Seizure History

Note from Nurse

Standard Seizure Protocol

Seizure Information Sheet

Severe Allergies/Anaphylaxis (EPI Pen)

Note from Nurse

Permission to Carry Medication

Medication Administration During School Hours Note from Nurse Doctor's Order for Medication During School Hours