School District No. 40 Medical Alert Form

Transcription

1 Medical Alert Form Student s Full Name: Birthdate: Wears Medic Alert ID First Parent/Legal Guardian Same address as child Yes No Full Name: Relationship: Home Phone: Work Phone: Cell Phone Second Parent/Legal Guardian Same address as child Yes No Full Name: Relationship: Home Phone: Work Phone: Cell Phone: Physician/Licensed Medical Practitioner: Phone: Alternate Guardians/Emergency Contacts Full Name Address/City Phone Alternate Phone If you child has these conditions, please check: Epilepsy/Seizure Disorder Diabetes ADHD: Anaphylactic Shock (go to pg 5) Severe Asthma Other: Blood Disorder EpiPen Required Other: Severe Allergies List Allergens: For Epilepsy/Seizure Disorder: (please fill in): Main triggers: Warning symptoms: Describe what happens during a seizure: Describe the care to provide before & after a seizure: How often does a seizure occur? When was the last seizure? When would you like to be contacted following a seizure? At what point to call ambulance? Standard procedure is following a 5 min or longer seizure Is an Emergency Response Plan Required? Yes No If an emergency response is needed at the school, please check off those actions that apply. Also indicate the order (i.e. 1-5) in which they should be done. Check all that apply Order Comments Parent/Guardian: Principal/Designate: Call 911 Call Parent / Guardian Call Emergency Contact Administer Medication/ Intervention Other To request medication to be administered at school (regularly or on an emergency basis) please complete page 4. Date Record Initiated: Signature Date Reviewed Medical Plans Version Page 3 of 8

2 Request for Administration of Medication at School Request for Administration of Medication at School Student s Full Name: School Name: Check if not applicable Section A To be completed by prescribing physician / licensed medical professional. Condition(s) which make medication necessary: Name of Medication Dosage Times Direction for Use Additional Comments (possible reactions, consequences of missing medication, storage duration): Physician s Name: Physician s Signature: Date: Office Stamp: Section B To be completed by parent/guardian Informed Authorization and Release I request that staff give medication, as prescribed on this consent form to my child. I understand that: ü I agree to supply the medication to the school, in the original container with the child s name, prescribing physician and pharmacist s direction for use including dosage. ü If changes occur, I will contact the school and provide revised instructions. I am aware I am required to update this information each September. ü I am aware that the Nursing Support Services for the school will be informed of my child s condition and medication and the nurse may contact me directly as necessary. ü I am aware that staff and other personnel working with my child will need to know of my child s condition and the medication required. ü If non-prescription medication is given, a note from the parent must be provided. Parent/Guardian Name: Principal/Designate: Print Name Signature Date Medical Plans Version Page 4 of 8

3 Medical Alert Form Allergens Symptoms: Check all that apply Peanuts Nuts Dairy Insects Latex Swelling (eyes, lips, face, tongue) Other: Additional Information: Emergency Response Plan Administer EpiPen Call 911 & request Advanced Life Support Ambulance Call Parent / Guardian Have ambulance transport to hospital Can student self-administer EpiPen? Yes No EpiPen Location 1: EpiPen Location 2: Difficulty in breathing or swallowing Flush face/body Cold, clammy skin Fainting /Loss of consciousness Dizziness/confusion Diarrhea Coughing Choking Coughing Wheezing Voice changes Vomiting Stomach cramps Symptoms vary: Anaphylaxis Prevention Strategies Elementary Schools Parent/Student Responsibilities: Inform teacher of allergy, emergency treatment and location of both EpiPens Ensure student wear a Medic Alert bracelet or necklace Ensure student with food allergies bring food/drinks from home Discuss appropriate location of both EpiPens with teacher/principal Teacher s Responsibilities: In consultations with parent/student/nursing Support Services, provide allergy awareness education to classmates Inform teacher on call of student with anaphylaxis, emergency treatment and location of both EpiPens For students with food allergy: In consultation with Nursing Support Service, provide allergy awareness education for classmates Encourage student not to share food, drinks or utensils Encourage a non-isolating eating environment for the student Encourage all students to wash hands with soapy water before and after eating Request that all desk be washed with soapy water after students eat Do not use the identified allergen(s) in classroom activities On field trips/co-curricular activities: Take both EpiPens, a copy of this form and a cellular phone Be aware of anaphylaxis exposure risk (food, latex and insect allergies) Inform supervising adults of student and emergency treatment Request supervising adults sit near students in a bus/vehicle Inform student with food allergens not to eat on bus/vehicle Anaphylaxis Prevention Strategies Middle/High Schools Parent/Student Responsibilities: Inform teacher of allergy, emergency treatment and location of both EpiPens Ensure student wear a Medic Alert bracelet or necklace Know anaphylactic risk an take measures to prevent anaphylaxis Ensure student know to keep EpiPen in a close location at all times, NOT in locker Ensure EpiPens are taken on field trips Teacher s Responsibilities: In consultations with parent/student/nursing Support Service, provide allergy awareness education to classmates Inform teacher on call of student with anaphylaxis, emergency treatment and location of both EpiPens For students with food allergy: Ensure student know to eat food brought from home Encourage all students to wash hands with soapy water before and after eating Request that all desk be washed with soapy water after students eat Do not use the identified allergen(s) in classroom activities On field trips/co-curricular activities: Ensure student takes both EpiPens Take a copy of this form and a cellular phone Inform supervising adults of student and emergency treatment Be aware of anaphylaxis exposure risk (food, latex and insect allergies) Refer to Learning Services Handbook, Anaphylaxis and Child Safety Responsibility Checklist Copy of the plan to parents Medical Plans Version Page 5 of 8

4 Medical Alert Form: Information and Training Section C Information and Training If training is required to administer the medication, please identify who has had the training and when it was completed. Most often parents are the trainer. If assistance from Nursing Support Services is required, please contact your school principal or designate. Name of Trainer: Nature of Training: Position: Date: People Trained Print Name Signature Date Principal or Designate Medical Plans Version Page 6 of 8

5 Medical Dispensing Record (for scheduled doses) Student Name: Staff Member s Name: Teacher s Name: Medication: Dosage: Time to be administered: Date Initials Date Initials Date Initials ü Create copy and staple to medication package Medical Plans Version Page 7 of 8

6 Medical Alert Form: Medical Emergencies Student: School: Div/HR: Teacher: Dear Parents/Guardians: In order to allow us to best be prepared for any medical emergency we would ask you to supply the following items or information (where checked):! Medical Alert Form (to be completed by parent/guardian)! Request for Administration of Medication at School (to be completed by parent/guardian and family physician) These forms need to be updated yearly. As children grow they may require a different dose of medication, may out-grow a condition or they may have a new issue the school needs to be aware of. If your child requires a staff member to assist with/or administer medication during school the Request for Administration of Medication at School must be signed by your Family Physician. In regards to EpiPens, parents should discuss emergency plans with school administration and school staff. Parents should provide one EpiPen to be carried on the child at all times. We strongly recommend you provide a second EpiPen to be kept at the school office. It is the parent's responsibility to provide a safe carrying case for the EpiPen; generally in a hip-sack or belt-clip. Parents must ensure that any medication intended for the child has not reached its "best before" or expiry date. Please make a note of your child's medication expiration date and replace your child's medication before this date. Medication on hand in the school office will be: expiring expiring Please advise below if the student normally keeps medication anywhere other than the school office: Medication: Medication: Location: Exp. Location: Exp. Any special comments: Please keep the office advised of all changes in your child's medical condition or medication. Please return all forms as soon as possible. Thank you. Medical Plans Version Page 8 of 8

7 Diabetes Support Plan & Medical Alert Information Instructions: This form is a communication tool for use by parents to share information with the school. Students who are receiving Nursing Support Services (NSS) Delegated Care do not need to complete page 3. This form does NOT need to be completed by Diabetes Clinic staff, Nursing Support Service Coordinators or Public Health Nurses. Name of Student: Date of Birth; School: Grade: Teacher/Div: Care Card Number: Date of Plan: CONTACT INFORMATION Parent/Guardian 1: Name: Call First Phone Numbers: Cell Work Home Other Parent/Guardian 2: Name: Call First Phone Numbers: Cell: Work: Home: Other: Other/Emergency: Name: Able to advise on diabetes care: Yes No Relationship: Phone Numbers: Cell: Work: Home: Other: Have emergency supplies been provided in the event of a natural disaster? Yes No If yes, location of emergency supply of insulin: STUDENTS RECEIVING NSS DELEGATED CARE NSS Coordinator: Phone: School staff providing delegated care: Parent Signature: Name: Date:

8 Diabetes Support Plan Student: MEDICAL ALERT - TREATING MILD TO MODERATE LOW BLOOD GLUCOSE NOTE: PROMPT ATTENTION CAN PREVENT SEVERE LOW BLOOD SUGAR SYMPTOMS Shaky, sweaty Hungry Pale Dizzy Irritable Tired/sleepy Blurry vision Confused Poor coordination Difficulty speaking Headache Difficulty concentrating Other: TREATMENT FOR STUDENTS NEEDING ASSISTANCE (anyone can give sugar to a student): Location of fast acting sugar: 1. If student able to swallow, give one of the following fast acting sugars: 10 grams glucose tablets 1/2 cup of juice or regular soft drink 2 teaspoons of honey 10 skittles 10 ml (2 teaspoons) or 2 packets of table sugar dissolved in water Other (ONLY if 10 grams are labelled on package): 2. Contact designated emergency school staff person OR 15 grams glucose tablets 3/4 cup of juice or regular soft drink 1 tablespoon of honey 15 skittles 15 ml (1 tablespoon) or 3 packets of table sugar dissolved in water Other (ONLY if 15 grams are labelled on package): 3. Blood glucose should be retested in 15 minutes. Retreat as above if symptoms do not improve or if blood glucose remains below 4 mmol/l 4. Do not leave student unattended until blood glucose 4 mmol/l or above 5. Give an extra snack such as cheese and crackers if next planned meal/snack is not for 45 minutes. MEDICAL ALERT GIVING GLUCAGON FOR SEVERE LOW BLOOD GLUCOSE SYMPTOMS PLAN OF ACTION Unconsciousness Having a seizure (or jerky movements) So uncooperative that you cannot give juice or sugar by mouth Place on left side and maintain airway Call 911, then notify parents Manage a seizure: protect head, clear area of hard or sharp objects, guide arms and legs but do not forcibly restrain, do not put anything in mouth Administer glucagon Medication Dose & Route Directions Glucagon (GlucaGen or Lilly Glucagon) Frequency: Emergency treatment for severe low blood glucose 0.5 mg = 0.5 ml. (for students 5 years of age and under) OR 1.0 mg =1.0 ml (for students 6 years of age and over) Give by injection: Intramuscular Remove cap Inject liquid from syringe into dry powder bottle Roll bottle gently to dissolve powder Draw fluid dose back into the syringe Inject into outer mid-thigh (may go through clothing) Once student is alert, give juice or fast acting sugar Page 2 of 3

9 Diabetes Support Plan Student: LEVEL OF SUPPORT REQUIRED FOR STUDENTS NOT RECEIVING NSS DELEGATED CARE Requires checking that task is done (child is proficient in task): Blood glucose testing Carb counting/adding Administers insulin Eating on time if on NPH insulin Act based on BG result Requires reminding to complete: Blood glucose testing Carb counting/adding Insulin administration Eating on time if on NPH insulin Act based on BG result Student is completely independent MEAL PLANNING: The maintenance of a proper balance of food, insulin and physical activity is important to achieving good blood glucose control in students with diabetes. In circumstances when treats or classroom food is provided but not labelled, the student is to: Call the parent for instructions Manage independently BLOOD GLUCOSE TESTING: Students must be allowed to check blood glucose level and respond to the results in the classroom, at every school location or at any school activity. If preferred by the student, a private location to do blood glucose monitoring must be provided, unless low blood sugar is suspected. Frequency of Testing: midmorning lunchtime mid afternoon before sport or exercise With symptoms of hyper/hypoglycemia Before leaving school Location of equipment: With student In classroom In office Other Time of day when low blood glucose is most likely to occur: Instructions if student takes school bus home: PHYSICAL ACTIVITY: Physical exercise can lower the blood glucose level. A source of fast-acting sugar should be within reach of the student at all times (see page 2 for more details). Blood glucose monitoring is often performed prior to exercise. Extra carbohydrates may need to be eaten based on the blood glucose level and the expected intensity of the exercise. Comments: INSULIN: All students with type 1 diabetes use insulin. Some students require insulin during the school day, most commonly before meals. Is insulin required at school on a daily basis? Yes No Insulin delivery system: Pump Pen Needle and syringe (at home or student fully independent) Frequency of insulin administration: Location of insulin: with student In classroom In office Other Insulin should never be stored in a locked cupboard. Page 3 of 3