Welcome to Cleveland Hill!

Transcription

1 Welcome to Cleveland Hill! We are so glad you are here! This is some important information from the health office: An updated immunization record is required by the start of school. This may be obtained from your health care provider or the health department. A physical examination performed within the last 12 months is required by the start of school. You may obtain a copy from your health care provider. The school nurse will perform annual vision and hearing screenings. You will be notified if abnormal findings are found. If your child is ill, i.e. fever, vomiting or diarrhea, please keep him/her home for 24 hours. To report your child absent, please call Please send a note when your child returns explaining the absence. If your child is absent four days or more, a doctor s note is necessary. If your child has a contagious/communicable disease, such as strep throat or pink eye, a doctor s note clearing them to return to school is needed. If your child needs to be excused from gym for one day, the nurse can give him/her a pass. However, any longer period of time off requires a doctor s note. The school nurse may administer prescription and OTC medication to your child. A doctor s order and medication permission form signed by a parent is required. If your child has a medical condition such as allergies or asthma, please inform the school nurse and keep her informed of any changes. Please update your contact numbers with the district. It is important to be able to reach you in case of an emergency. Accidents happen, so it is a good idea to keep a change of clothes here. Looking forward to a safe and healthy year!

2 WHEN TO KEEP A CHILD HOME WITH ILLNESS It can be difficult as parent to decide whether to send your child(ren) to school when they do not feel well. In general, unless your child is significantly ill, the best place for them is in school. However, there are some situations in which it is best to plan on keeping your child to rest, or to arrange for an appointment with your health care provider. The following are a few situations that warrant staying home and/or calling your health care provider:! A FEVER in the last 24 hours or greater. Do not give your child Tylenol, and send them to school if they have had a fever in the past 24 hours. You child is contagious to other children until they are fever free for 24 hours.! Child that is TOO SLEEPY due to illness keeping them up at night.! VOMITING and/or DIARRHEA in the past 24 hours.! PERSISTANT OR UNCONTROLABLE COUGH every few minutes, that makes a child feel uncomfortable, or is keeping them up at night.! SEVERE SORE THROAT with or without fever, especially after known exposure to Strep throat infection.! RASHES Honey-crusted sores around the nose or mouth, and a rash in various stages including boils, sores and bumps; especially if accompanied by other symptoms of illness such as fever. Your child s Pediatrician MUST clear ALL RASHES.! BRIGHT RED ITCHY EYES with or without discharge.! Large amount of NASAL DISCHARGE, especially if discolored and accompanied by facial pain/headache! SEVERE EAR PAIN or drainage from the ear; with or without fever.! SEVERE OR PERSISTANT HEADACHE, especially if accompanied by fever.! HEAD LICE must show proof of treatment and be cleared by the school nurse. Please notify the nurse immediately if your child has had any of the following: Chicken pox, Scabies, Conjunctivitis, Head Lice, Pneumonia, Strep infection, Pertussis, Shingles, Pinworms, Hand Foot and Mouth Disease, Fifth s Disease, Ringworm, or Impetigo If you child has any of the above symptoms it is better to let them stay home until they are feeling better, and are ready to learn for a full day in a classroom. When in doubt please contact your child s pediatrician. (In most cases they can return 24 hours after symptom free or 24 hours after the start of medication) Debra Czuprynski, RN Cleveland Hill School Nurse

3 Cleveland Hill Schools Health Examination Requirements Dear Parents/Guardians, Date: New York State law requires a health examination for all students entering the school district for the first time and when entering Pre-K or K, 1 st, 3 rd, 5 th, 7 th, 9 th & 11 th grades. The examination must be completed by a New York State licensed physician, physician assistant, or nurse practitioner. A dental certificate which states that your child has been seen by a dentist or dental hygienist is also requested. A copy of the health examination must be provided to the school when your child is a new enterer in school, and also when your child starts Pre-K, K, 1 st, 3 rd, 5 th, 7 th, 9 th, & 11 th grades. Communication between healthcare providers and school health staff is important for safe and effective care at school. Your healthcare provider may not share health information with school health staff without your signed permission. Please talk to your healthcare provider about signing their consent form for the school at the time of your child s appointment. We suggest you make copies of the completed forms for your own records before sending them to the school health office. Forms may also be faxed to ES or MS/HS Sincerely, Cleveland Hill School Health Office

4 Health Office Guidelines New York State Public Health Law, Section 2164 mandates that schools not permit a child to be admitted unless the parent/guardian provides the school with a certificate of immunization or proof from of a physician that the child is in the process or receiving the required immunizations. Required Immunizations for Kindergarten Immunization Number of Doses Polio 4 doses or 3 if the 3 rd dose at 4 years of age or older Hepatitis B 3 Diphtheria/Tetanus/Pertussis 5 doses or 4 doses if the 4 th dose given at 4 years of age or older or 3 doses if series started at age 7 or older Measles/Mumps/Rubella 2 Varicella (ChickenPox) 2 All new student and transfer students from within New York State must present proof of mandated immunizations within 14 calendar days of the first day of school attendance. Transfer students from outside New York State must present proof of mandated immunizations within 30 calendar days of the first day of school attendance.

5 Cleveland Hill School District STUDENT HEALTH EXAMINATION FORM (To be completed by private health care provider or school medical director) Note: NYSED requires an annual physical exam for new entrants and students in Grades pre K or K, 2, 4, 7 & 10, interscholastic sports and working papers Name: DOB: / / Gender: M F School: Grade: NA Exam Date: / / Specify Current Diseases HEALTH HISTORY Sickle Cell Screen: Positive Negative Not Done Date: / / Asthma (Intermittent or Persistent ) PPD: Positive Negative Not Done Date: / / Quick relief inhaler Yes No Elevated Lead: Yes No Not Done Date: / / Asthma Action Plan: Yes No Dental Referral: Yes No Not Done Date: / / Type 1 Diabetes Type 2 Diabetes Hyperlipidemia Hypertension Allergies See page 2 for details. Other: Significant Medical/Surgical Information: PHYSICAL EXAMINATION Height: Weight: BP: Pulse: Respirations: Scoliosis: Negative Positive Vision: Degree of deviation: Distance acuity Angle of trunk rotation via scoliometer: Distance acuity with lenses Body Mass Index: Vision near vision Weight Status Category (BMI Percentile): Vision color perception <5th 85 th 94 th 5 th 49 th 95 th 98 th Hearing: Right Left Referral Yes No Pass Fail Right Left Referral 50 th 84 th 99 th & higher 20 db sweep screen both ears or Circle developmental stage (ONLY for selection classification for 7th & 8th graders): Tanner: I. II. III. IV. V. SYSTEM REVIEW AND EXAM ENTIRELY NORMAL Specify any abnormalities: Yes No See attached. RECOMMENDATIONS OR RESTRICTIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK Free from contagions and physically qualified for all activities (phys ed, athletics, playground, work, school) Expected Body Contact (full or limited): football, wrestling, basketball, ice/field/floor hockey, baseball, softball, Strenuous: cross country, gymnastics, track & field, swim, diving, crew, ski, cheering, tennis, badminton, fencing, Non contact/non strenuous: bowling, golfing, table tennis, archery, riflery, shuffleboard, walking Protective Equipment: Athletic Cup Sport/safety goggles Other: Medical/prosthetic device: Recommendations/restrictions: Name: Page 1 of 2 DOB: / /

6 MEDICATIONS To be completed by Health Care Provider Diagnosis ICD Code Medication Name Dose Route Time Self Directed* Self Admin/ Self Carry** *Self Directed: I assess this student is self directed regarding their medication. They understand the purpose, name, amount, dose, timing and effect of taking or not taking the medication, can recognize the medication and refuse to take it inappropriately, and can ingest, inhale, apply or calculate and administer the correct dose of the medication independently **Self Admin/Self Carry: I have determined this student is consistent and responsible in taking their own medication (self directed), and in addition, give them permission to self carry and self administer this medication. They will be considered independent in medication delivery and need intervention only during emergencies. To be completed by Parent/Guardian if medication is prescribed I give permission for the above medication to be administered to my child as ordered by my health care provider. I will furnish the medication in the original pharmacy container, properly labeled with directions and dosage, or original over the counter medication container/package with my child's name on it. Parent/Guardian Signature: Date: Phone: ( ) Parent permission & provider consent is required for students to self administer & self carry medication. Students with this designation are considered independent in taking their medication at school and require no supervision by the nurse. Parents assume responsibility for ensuring that their child is carrying and taking their medication as ordered. Schools may revoke the self carry/self administer privilege if the student proves to be irresponsible or incapable. To request this option please sign below. Parent/Guardian Signature: Date: Phone: ( ) ALLERGIES None Non Life Threatening Life Threatening Type: Food Insect Latex Medication Seasonal/Environmental Other: Specify allergen(s): Specify previous symptoms: History of anaphylaxis; last occurrence: Emergency Care Plan for anaphylaxis: Yes No Treatment prescribed: None Antihistimine Epinephrine Autoinjector Immunization record attached Immunizations reported on NYSIIS IMMUNIZATIONS Immunizations received today: No immunizations received today Will return on / / to receive: Provider / Parental Authorization All information contained herein is valid through the last day of the month for 12 months from the date below. Medical Provider Signature: Date: Provider Name: (please print) Phone #: Provider Address: Fax #: Parent/Guardian Signature: Date: Return to: School Nurse: School: Phone #: ( ) Fax: ( ) Date: Page 2 of 2

7 Cleveland Hill School District STUDENT HEALTH HISTORY UPDATE Name: Parent/Guardian: (person completing this form) DOB: Grade: Home Phone: Cell Phone: Age: Gender:! M! F Date: Has your child ever: YES NO If Yes, please explain and include date: Had an ongoing medical condition!! Seen a medical specialist!! Had allergies:!!!food!environmental!insect!medication!other Been hospitalization!! Had an operation!! Had an injury requiring an Emergency Room visit!! Missed 5 days of school in a row due to illness/injury!! Had a bone/muscle injury!! Passed out, had a concussion or serious head injury!! Had a convulsion/seizure!! Had a vision problem or condition!!! glasses! contacts Had a hearing problem or condition!!! hearing aid! cochlear implant Worn dental bridge, braces or mouthpiece!! Have any family members under the age of 50 ever: YES NO If Yes, please specify: Had a heart attack!! Had other serious health problems!! CHECK ALL THAT APPLY TO YOUR CHILD:! ADHD! Asthma/trouble breathing! Autism/Asperger! Dental Injuries! Diabetes! Ear Infections! GI Conditions (ulcer, reflux, IBS)! Headaches/migraines! Heart Conditions! High Blood Pressure! Mental Health Condition (depression, eating disorder, anxiety, OCD, ODD, etc.)! Scoliosis! Single Organ (!kidney,!testicle)! Skin Condition! Speech Condition! Urinary Condition CURRENT MEDICATIONS YES NO Please list name, dose, time(s) Given at school!! Taken at home!! ASSISTIVE EQUIPMENT YES NO Please check all that apply During or outside of school!!!crutches!walker!wheelchair!other: TREATMENTS YES NO During or outside of school!!!insulin/blood glucose monitoring!inhaler/nebulizer/peak flow monitoring!special diet Is there any condition that would prevent your child from participating in physical education or sports?!no!yes: Please list any additional concerns: (use back of sheet if necessary) Parent/Guardian Signature: Date: This sample resource was created by the New York Statewide School Health Services Center and is located at SN Tool Kit 8/14

8 CLEVELAND HILL MEDICATION PLAN Dear Parent/Guardian: New York State requires 3 key components in order for us to administer medication to your child at school, or during field trips. The first component is a doctor s order. This is different from an Action Plan (asthma/allergy/seizure). We require a separate doctor s order with your child s name, diagnosis, medication, dosage, route, time, and any special instructions. The second component is parent permission. It should state that you give appropriate school staff permission to administer the medication to your child. The last component is the medication itself. A prescription medication will need to be in the original container with a pharmacy label. Over-thecounter medications must also be in an original container and labeled with a name. Your child will NOT BE GIVEN MEDICATION until all three of these are in components are in place. A form has been attached for your convenience. ALL MEDICATIONS MUST BE DELIVERED TO SCHOOL BY A PARENT/GUARDIAN *** A NEW ORDER IS REQUIRED EVERY SCHOOL YEAR *** Thank you, Debra Czuprynski, RN Cleveland Hill Nurse x 8209

9 Cleveland Hill School Provider and Parent Permission to Administer Medication at School/School Sponsored Events Student Name: To Be Completed By Parent Grade: Teacher/HR: DOB: School: I request the school nurse give the medication listed on this plan; or after the nurse determines my child can take their own medications; trained staff may assist my child to take their own medications. I will provide the medication in the original pharmacy or over the counter container. This plan will be shared with school staff caring for my child. Parent/Guardian Signature Date Phone Where We Can Reach You! Check if Cell To Be Completed By Health Care Provider-Valid for 1 Year Diagnosis Medication Dose Route Time(s) Recommendations ICD Code Note: Medication will be given as close to the prescribed time as possible, but may be given up to one hour before or after the prescribed time. Please advise if there is a time-specific concern regarding administration.! Independent Carry and Use Attestation Attached (Required for Independent Carry and Use) NYS law requires both provider attestation that the student has demonstrated they can effectively self- administer inhaled respiratory rescue medications, epinephrine auto-injector, Insulin, carry glucagon and diabetes supplies or other medications which require rapid administration along with parent/guardian permission delivery to allow this option in school. Check this box and attach the attestation to this form to request this option. Name/Title of Prescriber (Please Print) Stamp Date Prescriber s Signature Phone Return to: School Nurse: School: School Address: Phone: ( ) Fax: ( ) This sample resource is located at Forms Notifications 12/16

10 School DOB Health Care Provider Provider s Phone ASTHMA ACTION PLAN / / DO NOT WRITE IN THIS SPACE Pare Parent s Phone Place Patient Label Here Colds Exercise Animals Dust Food Weather Other Green Zone: Go! Take these CONTROL (PREVENTION) Medicines EVERY Day You have ALL of these: wheeze No control medicines required. Continue Medication: New Medication: For asthma with exercise, ADD:, puff(s) with spacer 15 minutes before exercise Always rinse mouth after using your daily inhaled medicine. Yellow Zone: Caution! Continue CONTROL Medicines and ADD QUICK-RELIEF Medicines You have ANY of these: wheeze Controller Medicine and add this Rescue only if needed. only ifneeded. Red Zone: EMERGENCY! Continue CONTROL & QUICK-RELIEF Medicines and GET HELP! You have ANY of these: breath and fast puffs every15 minutes OR nebulizer treatments every Other IF YOU CANNOT CONTACT YOUR DOCTOR: Phone: WCHOB-669 Rev. /1/1

11 ASTHMA EDUCATION Asthma is a long-term or chronic disease of the airways in the lungs. It causes the following changes in the lungs: 1. Swelling (or inflammation) in the linings of the airways. 2. Tightening (or squeezing) of the muscles around the airways. 3. Increased mucous production in the airways. Asthma Normal Airway The good news is that asthma can be controlled if managed well. It may even become inactive for long periods of time. 1. DO NOT SMOKE OR ALLOW YOUR CHILD TO BE EXPOSED TO ANY TYPE OF SMOKE, INCLUDING CIGARETTE AND MARIJUANA SMOKE IN ANY HOME OR CAR. 2. Avoid your child s asthma triggers. 3. All patients with asthma should get a flu vaccine every year because they are at a higher risk of getting very sick if they get the flu infection. 4. All patients with asthma should be seen by their doctor at least twice a year. If your asthma is more severe, your doctor will want to see you more often. 5. If your child has any of these symptoms, you should call your doctor s office for an appointment sometime in the next 2 weeks. a. Wheezing more than 2 times per week in the last month. b. Waking up at night wheezing more than 2 times in the last month. c. Using Albuterol or Xopenex, (rescue medicine) more than 2 times per week in the last month. d. Feel your child s asthma is limiting his/her activity, (can t go to school, play with friends or play sports). e. Feel your child s asthma is not well controlled. 6. How to help keep your child s asthma under control: a. If you smoke, quit. New York State Smoker s quit line is NYQUITS. b. Stay on Controller Medication until your doctor tells you to stop. c. Discuss with your primary care provider if your child needs to use Albuterol prior to exercise. d. Keep stuffed toys out of your child s bed. e. Remove dust weekly. If possible, use HEPA filter vacuum or electrostatic dusting cloth. f. Wash sheets and blankets once a week in hot water. g. Put dust-mite proof covers around your mattress and pillow. h. If you do not have a cat or dog, do not get one. i. If you already have a cat or dog, keep them out of your child s bedroom. j. Avoid exposure to wood burning stoves and fire places. k. Change your furnace filters every 1-2 months.

12 Name: D.O.B.: Allergy to: PLACE PICTURE HERE Weight: lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE. Extremely reactive to the following allergens: THEREFORE: [ ] 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. FOR ANY OF THE FOLLOWING: SEVERE SYMPTOMS MILD SYMPTOMS LUNG Shortness of breath, wheezing, repetitive cough SKIN Many hives over body, widespread redness HEART Pale or bluish skin, faintness, weak pulse, dizziness GUT Repetitive vomiting, severe diarrhea 1. INJECT EPINEPHRINE IMMEDIATELY. 2. Call 911. Tell emergency dispatcher the person is having anaphylaxis and may need epinephrine when emergency responders arrive. Consider giving additional medications following epinephrine:» Antihistamine» Inhaler (bronchodilator) if wheezing 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. If symptoms do not improve, or symptoms return, more doses of epinephrine can be given about 5 minutes or more after the last dose. Alert emergency contacts. THROAT Tight or hoarse throat, trouble breathing or swallowing OTHER Feeling something bad is about to happen, anxiety, confusion MOUTH Significant swelling of the tongue or lips OR A COMBINATION of symptoms from different body areas. Transport patient to ER, even if symptoms resolve. Patient should remain in ER for at least 4 hours because symptoms may return. NOSE Itchy or runny nose, sneezing MOUTH Itchy mouth SKIN A few hives, mild itch GUT Mild nausea or discomfort FOR MILD SYMPTOMS FROM MORE THAN ONE SYSTEM AREA, GIVE EPINEPHRINE. FOR MILD SYMPTOMS FROM A SINGLE SYSTEM AREA, FOLLOW THE DIRECTIONS BELOW: 1. Antihistamines may be given, if ordered by a healthcare provider. 2. Stay with the person; alert emergency contacts. 3. Watch closely for changes. If symptoms worsen, give epinephrine. MEDICATIONS/DOSES Epinephrine Brand or Generic: Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM Antihistamine Brand or Generic: Antihistamine Dose: Other (e.g., inhaler-bronchodilator if wheezing): PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017

13 HOW TO USE AUVI-Q (EPINEPHRINE INJECTION, USP), KALEO 1. Remove Auvi-Q from the outer case. 2. Pull off red safety guard. 3. Place black end of Auvi-Q against the middle of the outer thigh. 4. Press firmly, and hold in place for 5 seconds. 5. Call 911 and get emergency medical help right away. 3 HOW TO USE EPIPEN AND EPIPEN JR (EPINEPHRINE) AUTO-INJECTOR, MYLAN 1. Remove the EpiPen or EpiPen Jr Auto-Injector from the clear carrier tube. 2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up. 4. Swing and push the auto-injector firmly into the middle of the outer thigh until it clicks. 5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3). 6. Remove and massage the injection area for 10 seconds. 7. Call 911 and get emergency medical help right away. 3 4 HOW TO USE EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF EPIPEN ), USP AUTO-INJECTOR, MYLAN 1. Remove the epinephrine auto-injector from the clear carrier tube Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up. 4. Swing and push the auto-injector firmly into the middle of the outer thigh until it clicks Hold firmly in place for 3 seconds (count slowly 1, 2, 3). 6. Remove and massage the injection area for 10 seconds. 7. Call 911 and get emergency medical help right away. HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK ), USP AUTO-INJECTOR, IMPAX LABORATORIES 1. Remove epinephrine auto-injector from its protective carrying case. 2. Pull off both blue end caps: you will now see a red tip. 3. Grasp the auto-injector in your fist with the red tip pointing downward. 4. Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh. 5. Press down hard and hold firmly against the thigh for approximately 10 seconds. 6. Remove and massage the area for 10 seconds. 7. Call 911 and get emergency medical help right away. 5 ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS: 1. Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer thigh. In case of accidental injection, go immediately to the nearest emergency room. 2. If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries. 3. Epinephrine can be injected through clothing if needed. 4. Call 911 immediately after injection. OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.): Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly. EMERGENCY CONTACTS CALL 911 RESCUE SQUAD: DOCTOR: PHONE: PARENT/GUARDIAN: PHONE: OTHER EMERGENCY CONTACTS NAME/RELATIONSHIP: PHONE: NAME/RELATIONSHIP: FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017 PHONE:

14 Cleveland Hill School District SEIZURE DISORDER Emergency Care Plan Student: Grade: School Contact: DOB: Mother: MHome #: MWork #: MCell #: Father: FHome #: FWork #: FCell #: Emergency Contact: Relationship: Phone: SYMPTOMS OF A SEIZURE EPISODE MAY INCLUDE ANY/ALL OF THESE:! Tonic-Clonic Seizure: Symptoms may include an aura, muscle rigidity, followed by violent muscle contractions, loss of alertness (consciousness), biting the cheek or tongue, clenched teeth or jaw, loss of bladder or bowel control, difficulty breathing, blue skin color.! Simple Focal Seizure: The person will remain conscious but experience unusual feelings or sensations that can take many forms, may experience sudden and unexplainable feelings of joy, anger, sadness, or nausea. He/she also may hear, smell, taste, see, or feel things that are not real.! Complex Focal Seizure: The person has a change in or loss of consciousness. His or her consciousness may be altered, producing a dreamlike experience. People having a complex focal seizure may display strange, repetitious behaviors such as blinks, twitches, mouth movements, or even walking in a circle. These repetitious movements are called automatisms. More complicated actions, which may seem purposeful, can also occur involuntarily. Patients may also continue activities they started before the seizure began, such as washing dishes in a repetitive, unproductive fashion. These seizures usually last just a few seconds.!absence: Symptoms may be brief lasting only a few seconds and occur several times a day. During the seizure the person may: stop walking and start again a few seconds later, stop talking in mid-sentence and start again a few seconds later. Specific symptoms of typical petit mal seizures may include: changes in muscle activity (hand fumbling, fluttering eyelids, lip smacking, chewing), change in alertness (staring and lack of awareness) STAFF MEMBERS INSTRUCTED: " Classroom Teacher(s) " Special Area Teacher(s) " Administration " Support Staff " Transportation Staff TREATMENT: Clear the area around the student to avoid injury. DO NOT PUT ANYTHING IN THE STUDENT S MOUTH Place student on side if possible, speak to student in reassuring tone. Stay with student until help arrives " Emergency Medical Services (911) should be called, student transported to hospital Preferred Hospital if transported: " Emergency medication to be given by Nurse at onset of seizure " Student should be allowed to rest following seizure, call parent Transportation Plan: " Medication available on bus " Medication NOT available on bus " Does not ride bus Special instructions: Healthcare Provider Signature: Written by: Date: Phone: Date: " Copy provided to Parent " Copy sent to Healthcare Provider Parent/Guardian Signature to share this plan with Provider and School Staff: This sample resource may be found at Forms Notifications 12/16