Athletic Participation Directions for Parents/Guardians & Student-Athletes Step 1: Downloading the Athletic Physical/Medical Packet Go to the Cherokee Athletics Page at: WWW.LRHSD.ORG/DOMAIN/419 Download the Season Specific Sports Physical/Medical Packet The Pages are designed for Double-Sided Printing but can be printed single-sided Packets are available in the North & South offices if you are unable to print on your own Step 2: Completing the Athletic Physical/Medical Packet Complete the downloaded Sports Physical/Medical Packet A portion of the packet will be completed by you A portion of the packet will be completed by a physician, if a new physical is needed Step 3: Online Registration by Parents/Guardians & Student-Athletes (Completed Every Season) Go to the Cherokee Athletics webpage at: WWW.LRHSD.ORG/DOMAIN/419, click Register or go directly to the Family ID webpage HTTPS://WWW.FAMILYID.COM/ORGANIZATIONS/CHEROKEE Log In (if you have previously created an account) or Sign Up (if you are new to the system) Follow the process of registering your student-athlete. Be sure to SUBMIT when completed. FYI This website does not collect any payments. See STEP 5 for making participation fee payment. Step 4: Submit Completed Sports Physical/Medical Paperwork Submit the Completed Sports Physical/Medical Paperwork to Jeff Wood, Athletic Trainer in Cherokee s South Main Office or the Training Room by Step 5: Submit the Activity/Athletic Fee Payment (if not done so already) Option 1: Preferred method of payment is the electronic payment system that will be accessible on WWW.LRHSD.ORG and look for Participation Fee Payment to submit the fee for the upcoming school year. Option 2: Download payment form at WWW.LRHSD.ORG/PAGE/601 and submit form along with check, money order or certified bank check to NORTH MAIN OFFICE (SEE VAL D AMATO). Include the STUDENT ID# on the check. Make checks payable to: Lenape Regional High School District (LRHSD). Cash payment will not be accepted. PLEASE NOTE: No Athlete will be allowed to participate until ALL of the above steps are completed by the above deadlines and ALL of their paperwork has been processed through the Athletic Training Room. Physical Examinations must be reviewed and approved by the Lenape District School Physicians prior to an athlete being declared medically eligible to practice. This process could take up to 3-5 days. Athletes are encouraged to have all their paperwork turned into the Athletic Training Room as soon as possible prior to the start of the season. THE ATHLETIC TRAINERS STRONGLY SUGGESTS THE COMPLETED PACKET BE SUBMITTED 1 FULL WEEK PRIOR TO THE START OF THE FIRST DAY OF PRACTICE.
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CHEROKEE HIGH SCHOOL Grade: SPRING SPORTS PACKET Gender: Male or Female The First Official Day of Practice for 2018 Spring Season: Friday, March 2, 2018 SPORTS PHYSICAL: ALL sports physical examination dates MUST be within 365 days of the 1 st Day of Practice Listed Above If you already have a current sports physical on file at Cherokee that is within 365 days of the start of the season then a new sports physical is not required, but the Medical Health History Update Questionnaire is still required to be completed by the parents for each season of participation. The examining physician MUST sign the sports physical on page # 5 and #6 in the areas of Signature of Physician and in the area at the very bottom of page #6 Completed Cardiac Assessment Module - The area for HCP Office Stamp MUST also be stamped by the physician s office. Sports Physicals will NOT be accepted unless all 3 areas are signed by the physician and the office stamp is on the form. Make sure the VISION EXAM is completed on your sports physical form prior to turning it in many local pediatricians do not do the vision exam and it is required! ALL SPORTS PHYSICALS FORMS, ON-LINE REGISTRATION, & PARTICIPATION FEES PAID AT LEAST 1 WEEK PRIOR TO START OF SEASON ON Thursday, February 22, 2018 TO INSURE AN ATHLETE BEING CLEARED TO PRACTICE/TRY-OUT ON THE FIRST DAY OF OFFICIAL PRACTICE. PLEASE NOTE: No Athlete will be allowed to participate until ALL of their paperwork has been processed through the Athletic Training Room. Physical Examinations must be reviewed and approved by the Lenape District School Physicians prior to an athlete being declared medically eligible to practice. This process could take up to 3-5 days. Athletes are encouraged to have all their paperwork turned into the Athletic Traing Room as soon as possible prior to the start of the season.
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SCHOLASTIC STUDENT-ATHLETE SAFETY ACT INFORMATION FACT SHEET FOR PARENTS/GUARDIANS Prior to participation on a school-sponsored interscholastic or intramural athletic team or squad, each student-athlete in grades 6 through 12 must present a completed pre-participation physical evaluation (PPE) form to the designated school staff member. Important information regarding the PPE is provided below, and you should feel free to share with your child s medical home health care provider. 1) The PPE may ONLY be completed by a licensed physician, advanced practice nurse (APN) or physician assistant (PA) that has completed the Student-Athlete Cardiac Assessment professional development module. It is recommended that you verify that your medical provider has completed this module before scheduling an appointment for a PPE. 2) The required PPE must be conducted within 365 days prior to the first official practice in an athletic season. The PPE form is available in English and Spanish at http://www.state.nj.us/education/students/safety/health/records/athleticphysicalsform.pdf. 3) The parent/guardian must complete the History Form (page #3). 4) The parent/guardian must complete The Athlete with Special Needs: Supplemental History Form (page #4), if applicable, for a student with a disability that limits major life activities, and insert the date of the required physical examination on the top of the page. 5) The licensed physician, APN or PA who performs the physical examination must complete the remaining two pages of the PPE, and insert the date of the examination on the Physical Examination Form (page #5) and Clearance Form (page #6). 6) The school district must provide written notification to the parent/guardian, signed by the school physician, indicating approval of the student s participation in a school-sponsored interscholastic or intramural athletic team or squad based upon review of the medical report, or must provide the reason(s) for the disapproval of the student s participation. 7) For student-athletes that had a medical examination completed more than 90 days prior to the first official practice in an athletic season, the Health History Update Questionnaire (page #1) form must be completed, and signed by the student s parent/guardian. This HHQ must be reviewed by the school nurse and, if applicable, the school s athletic trainer. The Health History Update Questionnaire is available at http://www.state.nj.us/education/students/safety/health/records/healthhistoryupdate.pdf. For more information, please review the Frequently Asked Questions which are available at http://www.state.nj.us/education/students/safety/health/services/athlete/faq.pdf. You may also direct questions to Scott Agnew, Director of Athletics and Activities, at SAGNEW@LRHSD.ORG or 856-983-5140 x2291 or Jeff Wood, Athletic Trainer, at JWOOD@LRHSD.ORG or x2335.
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State of New Jersey Page 1 DEPARTMENT OF EDUCATION HEALTH HISTORY UPDATE QUESTIONNAIRE Name of School To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose physical examination was completed more than 90 days prior to the first day of official practice shall provide a health history update questionnaire completed and signed by the student s parent or guardian. Student Age Grade Date of Last Physical Examination Sport Since the last pre-participation physical examination, has your son/daughter: 1. Been medically advised not to participate in a sport? Yes No If yes, describe in detail 2. Sustained a concussion, been unconscious or lost memory from a blow to the head? Yes No If yes, explain in detail 3. Broken a bone or sprained/strained/dislocated any muscle or joints? Yes No If yes, describe in detail 4. Fainted or blacked out? Yes No If yes, was this during or immediately after exercise? 5. Experienced chest pains, shortness of breath or racing heart? Yes No If yes, explain 6. Has there been a recent history of fatigue and unusual tiredness? Yes No 7. Been hospitalized or had to go to the emergency room? Yes No If yes, explain in detail 8. Since the last physical examination, has there been a sudden death in the family or has any member of the family under age 50 had a heart attack or heart trouble? Yes 9. Started or stopped taking any over-the-counter or prescribed medications? Yes No If yes, name of medication(s) Date: Signature of parent/guardian PLEASE RETURN COMPLETED FROM TO THE SCHOOL TRAINER S OFFICE E14-00284
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Preparticipation Physical Evaluation HISTORY FORM (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep a copy of this form in the chart.) Date of Exam Name Date of birth Sex Age Grade School Sport(s) Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking Page 3 Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects Explain Yes answers below. Circle questions you don t know the answers to. GENERAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes Infections Other: 3. Have you ever spent the night in the hospital? 4. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU Yes No 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 7. Does your heart ever race or skip beats (irregular beats) during exercise? 8. Has a doctor ever told you that you have any heart problems? If so, check all that apply: High blood pressure A heart murmur High cholesterol A heart infection Kawasaki disease Other: 9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) 10. Do you get lightheaded or feel more short of breath than expected during exercise? 11. Have you ever had an unexplained seizure? 12. Do you get more tired or short of breath more quickly than your friends during exercise? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)? 14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? 15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? BONE AND JOINT QUESTIONS Yes No 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? 18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? 20. Have you ever had a stress fracture? 21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism) 22. Do you regularly use a brace, orthotics, or other assistive device? 23. Do you have a bone, muscle, or joint injury that bothers you? 24. Do any of your joints become painful, swollen, feel warm, or look red? 25. Do you have any history of juvenile arthritis or connective tissue disease? MEDICAL QUESTIONS Yes No 26. Do you cough, wheeze, or have difficulty breathing during or after exercise? 27. Have you ever used an inhaler or taken asthma medicine? 28. Is there anyone in your family who has asthma? 29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? 30. Do you have groin pain or a painful bulge or hernia in the groin area? 31. Have you had infectious mononucleosis (mono) within the last month? 32. Do you have any rashes, pressure sores, or other skin problems? 33. Have you had a herpes or MRSA skin infection? 34. Have you ever had a head injury or concussion? 35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? 36. Do you have a history of seizure disorder? 37. Do you have headaches with exercise? 38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? 39. Have you ever been unable to move your arms or legs after being hit or falling? 40. Have you ever become ill while exercising in the heat? 41. Do you get frequent muscle cramps when exercising? 42. Do you or someone in your family have sickle cell trait or disease? 43. Have you had any problems with your eyes or vision? 44. Have you had any eye injuries? 45. Do you wear glasses or contact lenses? 46. Do you wear protective eyewear, such as goggles or a face shield? 47. Do you worry about your weight? 48. Are you trying to or has anyone recommended that you gain or lose weight? 49. Are you on a special diet or do you avoid certain types of foods? 50. Have you ever had an eating disorder? 51. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY 52. Have you ever had a menstrual period? 53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months? Explain yes answers here I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete Signature of parent/guardian Date 2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503 9-2681/0410 New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
Preparticipation Physical Evaluation THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM Page 4 Date of Exam Name Date of birth Sex Age Grade School Sport(s) 1. Type of disability 2. Date of disability 3. Classification (if available) 4. Cause of disability (birth, disease, accident/trauma, other) 5. List the sports you are interested in playing 6. Do you regularly use a brace, assistive device, or prosthetic? 7. Do you use any special brace or assistive device for sports? 8. Do you have any rashes, pressure sores, or any other skin problems? 9. Do you have a hearing loss? Do you use a hearing aid? 10. Do you have a visual impairment? 11. Do you use any special devices for bowel or bladder function? 12. Do you have burning or discomfort when urinating? 13. Have you had autonomic dysreflexia? 14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness? 15. Do you have muscle spasticity? 16. Do you have frequent seizures that cannot be controlled by medication? Explain yes answers here Yes No Please indicate if you have ever had any of the following. Atlantoaxial instability X-ray evaluation for atlantoaxial instability Dislocated joints (more than one) Easy bleeding Enlarged spleen Hepatitis Osteopenia or osteoporosis Difficulty controlling bowel Difficulty controlling bladder Numbness or tingling in arms or hands Numbness or tingling in legs or feet Weakness in arms or hands Weakness in legs or feet Recent change in coordination Recent change in ability to walk Spina bifida Latex allergy Explain yes answers here Yes No I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete Signature of parent/guardian Date 2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM Name Date of birth PHYSICIAN REMINDERS 1. Consider additional questions on more sensitive issues Do you feel stressed out or under a lot of pressure? Do you ever feel sad, hopeless, depressed, or anxious? Do you feel safe at your home or residence? Have you ever tried cigarettes, chewing tobacco, snuff, or dip? During the past 30 days, did you use chewing tobacco, snuff, or dip? Do you drink alcohol or use any other drugs? Have you ever taken anabolic steroids or used any other performance supplement? Have you ever taken any supplements to help you gain or lose weight or improve your performance? Do you wear a seat belt, use a helmet, and use condoms? 2. Consider reviewing questions on cardiovascular symptoms (questions 5 14). EXAMINATION Height Weight Male Female BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Y N MEDICAL NORMAL ABNORMAL FINDINGS Appearance Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat Pupils equal Hearing Lymph nodes Heart a Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI) Pulses Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only) b Skin HSV, lesions suggestive of MRSA, tinea corporis Neurologic c MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional Duck-walk, single leg hop a Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. b Consider GU exam if in private setting. Having third party present is recommended. c Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion. Page 5 Date of Physical Examination: Cleared for all sports without restriction Cleared for all sports without restriction with recommendations for further evaluation or treatment for Not cleared Pending further evaluation For any sports For certain sports Reason Recommendations I have examined the above-named student and completed the preparticipation physical evaluation. The The athlete does does not not present present apparent clinical clinical contraindications to practice to practice and and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made availableto the school at the request of the parents. If Ifcondi- tions after arise the after athlete the athlete has been has cleared been cleared for participation, for participation, a physician the physician may rescind may the rescind clearance the clearance until theuntil problem the problem is resolved is resolved and the potential and the potential consequences consequences are completely are completely explained conditions arise explained to the athlete (and parents/guardians). to the athlete (and parents/guardians). Name of physician, advanced practice nurse (APN), physician assistant (PA) (print/type) Date Address Phone Signature of physician, APN, PA 2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503 9-2681/0410 New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
Page 6 Preparticipation Physical Evaluation CLEARANCE FORM Date of Examination: Name Sex M F Age Date of birth Cleared for all sports without restriction Cleared for all sports without restriction with recommendations for further evaluation or treatment for Not cleared Pending further evaluation For any sports For certain sports Reason Recommendations EMERGENCY INFORMATION Allergies Other information I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians). Name of physician, advanced practice nurse (APN), physician assistant (PA) Date Address Phone Signature of physician, APN, PA Completed Cardiac Assessment Professional Development Module Date Signature 2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
Sponsored by Asthma Treatment Plan Student Page 7 (This asthma action plan meets NJ Law N.J.S.A. 18A:40-12.8) (Physician s Orders) (Please Print) Name Doctor Phone HEALTHY (Green Zone) Date of Birth You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work, exercise, and play Parent/Guardian (if applicable) Phone Effective Date Emergency Contact Phone Take daily control medicine(s). Some inhalers may be more effective with a spacer use if directed. MEDICINE HOW MUCH to take and HOW OFTEN to take it Advair HFA 45, 115, 230 2 puffs twice a day Alvesco 80, 160 1, 2 puffs twice a day Dulera 100, 200 2 puffs twice a day Flovent 44, 110, 220 2 puffs twice a day Qvar 40, 80 1, 2 puffs twice a day Symbicort 80, 160 1, 2 puffs twice a day Advair Diskus 100, 250, 500 1 inhalation twice a day Asmanex Twisthaler 110, 220 1, 2 inhalations once or twice a day Flovent Diskus 50 100 250 1 inhalation twice a day Pulmicort Flexhaler 90, 180 1, 2 inhalations once or twice a day Pulmicort Respules (Budesonide) 0.25, 0.5, 1.0 1 unit nebulized once or twice a day Singulair (Montelukast) 4, 5, 10 mg 1 tablet daily Other None Triggers Check all items that trigger patient s asthma: Colds/flu Exercise Allergens Dust Mites, dust, stuffed animals, carpet Pollen - trees, grass, weeds Mold Pets - animal dander Pests - rodents, cockroaches Odors (Irritants) And/or Peak flow above Cigarette smoke & second hand Remember to rinse your mouth after taking inhaled medicine. smoke If exercise triggers your asthma, take this medicine minutes before exercise. Perfumes, cleaning products, Continue daily control medicine(s) and ADD quick-relief medicine(s). scented products You have any of these: MEDICINE HOW MUCH to take and HOW OFTEN to take it Smoke from Cough burning wood, Combivent Maxair Xopenex 2 puffs every 4 hours as needed Mild wheeze inside or outside Pro-Air Proventil 2 puffs every 4 hours as needed Ventolin Tight chest Weather Albuterol 1.25, 2.5 mg 1 unit nebulized every 4 hours as needed Sudden Coughing at night temperature Duoneb 1 unit nebulized every 4 hours as needed Other: change (Levalbuterol) 0.31, 0.63, 1.25 mg _1 unit nebulized every 4 hours as needed Xopenex Extreme weather Increase the dose of, or add: - hot and cold If quick-relief medicine does not help within Ozone alert days Other 15-20 minutes or has been used more than Foods: 2 times and symptoms persist, call your doctor or go to the emergency room. And/or Peak flow from to EMERGENCY (Red Zone) If quick-relief medicine is needed more than 2 times a week, except before exercise, then call your doctor. Your asthma is getting worse fast: Quick-relief medicine did not help within 15-20 minutes Breathing is hard or fast Nose opens wide Ribs show Trouble walking and talking Lips blue Fingernails blue Other: And/or Peak flow below Disclaimers: The use of this Website/PACNJ Asthma Treatment Plan and its content is at your own risk. The content is provided on an as is basis. The American Lung Association of the Mid-Atlantic (ALAM-A), the Pediatric/Adult Asthma Coalition of New Jersey and all affiliates disclaim all warranties, express or implied, statutory or otherwise, including but not limited to the implied warranties or merchantability, non-infringement of third parties rights, and fitness for a particular purpose. ALAM-A makes no representations or warranties about the accuracy, reliability, completeness, currency, or timeliness of the content. ALAM-A makes no warranty, representation or guaranty that the information will be uninterrupted or error free or that any defects can be corrected. In no event shall ALAM-A be liable for any damages (including, without limitation, incidental and consequential damages, personal injury/wrongful death, lost profits, or damages resulting from data or business interruption) resulting from the use or inability to use the content of this Asthma Treatment Plan whether based on warranty, contract, tort or any other legal theory, and whether or not ALAM-A is advised of the possibility of such damages. ALAM-A and its affiliates are not liable for any claim, whatsoever, caused by your use or misuse of the Asthma Treatment Plan, nor of this website. The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the American Lung Association in New Jersey. This publication was supported by a grant from the New Jersey Department of Health and Senior Services, with funds provided by the U.S. Centers for Disease Control and Prevention under Cooperative Agreement 5U59EH000491-04. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the New Jersey Department of Health and Senior Services or the U.S. Centers for Disease Control and Prevention. Although this document has been funded wholly or in part by the United States Environmental Protection Agency under Agreement XA96296601-0 to the American Lung Association in New Jersey, it has not gone through the Agency s publications review process and therefore, may not necessarily reflect the views of the Agency and no official endorsement should be inferred. Information in this publication is not intended to diagnose health problems or take the place of medical advice. For asthma or any medical condition, seek medical advice from your child s or your health care professional. Permission to reproduce blank form www.pacnj.org REVISED AUGUST 2013 Take these medicines NOW and CALL 911. Asthma can be a life-threatening illness. Do not wait! MEDICINE HOW MUCH to take and HOW OFTEN to take it Combivent Maxair Xopenex 2 puffs every 20 minutes Ventolin Pro-Air Proventil 2 puffs every 20 minutes Albuterol 1.25, 2.5 mg 1 unit nebulized every 20 minutes Duoneb 1 unit nebulized every 20 minutes Xopenex (Levalbuterol) 0.31, 0.63, 1.25 mg 1 unit nebulized every 20 minutes Other Permission to Self-administer Medication: This student is capable and has been instructed in the proper method of self-administering of the non-nebulized inhaled medications named above in accordance with NJ Law. This student is not approved to self-medicate. Other: This asthma treatment plan is meant to assist, not replace, the clinical decision-making required to meet individual patient needs. PHYSICIAN/APN/PA SIGNATURE DATE PARENT/GUARDIAN SIGNATURE PHYSICIAN STAMP Make a copy for parent and for physician file, send original to school trainer or child care provider.
Asthma Treatment Plan Student Parent Instructions Page 8 The PACNJ Asthma Treatment Plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. 1. Parents/Guardians: Before taking this form to your Health Care Provider, complete the top left section with: Child s name Child s doctor s name & phone number Parent/Guardian s name Child s date of birth An Emergency Contact person s name & phone number & phone number 2. Your Health Care Provider will complete the following areas: The effective date of this plan The medicine information for the Healthy, Caution and Emergency sections Your Health Care Provider will check the box next to the medication and check how much and how often to take it Your Health Care Provider may check OTHER and: v Write in asthma medications not listed on the form v Write in additional medications that will control your asthma v Write in generic medications in place of the name brand on the form Together you and your Health Care Provider will decide what asthma treatment is best for your child to follow 3. Parents/Guardians & Health Care Providers together will discuss and then complete the following areas: Child s peak flow range in the Healthy, Caution and Emergency sections on the left side of the form Child s asthma triggers on the right side of the form Permission to Self-administer Medication section at the bottom of the form: Discuss your child s ability to self-administer the inhaled medications, check the appropriate box, and then both you and your Health Care Provider must sign and date the form 4. Parents/Guardians: After completing the form with your Health Care Provider: Make copies of the Asthma Treatment Plan and give the signed original to your child s school nurse or child care provider Keep a copy easily available at home to help manage your child s asthma Give copies of the Asthma Treatment Plan to everyone who provides care for your child, for example: babysitters, before/after school program staff, coaches, scout leaders PARENT AUTHORIZATION I hereby give permission for my child to receive medication at school as prescribed in the Asthma Treatment Plan. Medication must be provided in its original prescription container properly labeled by a pharmacist or physician. I also give permission for the release and exchange of information between the school nurse and my child s health care provider concerning my child s health and medications. In addition, I understand that this information will be shared with school staff on a need to know basis. Parent/Guardian Signature Phone Date FILL OUT THE SECTION BELOW ONLY IF YOUR HEALTH CARE PROVIDER CHECKED PERMISSION FOR YOUR CHILD TO SELF-ADMINISTER ASTHMA MEDICATION ON THE FRONT OF THIS FORM. RECOMMENDATIONS ARE EFFECTIVE FOR ONE (1) SCHOOL YEAR ONLY AND MUST BE RENEWED ANNUALLY I do request that my child be ALLOWED to carry the following medication for self-administration in school pursuant to N.J.A.C:.6A:16-2.3. I give permission for my child to self-administer medication, as prescribed in this Asthma Treatment Plan for the current school year as I consider him/her to be responsible and capable of transporting, storing and self-administration of the medication. Medication must be kept in its original prescription container. I understand that the school district, agents and its employees shall incur no liability as a result of any condition or injury arising from the self-administration by the student of the medication prescribed on this form. I indemnify and hold harmless the School District, its agents and employees against any claims arising out of self-administration or lack of administration of this medication by the student. I DO NOT request that my child self-administer his/her asthma medication. Parent/Guardian Signature Phone Date Disclaimers: The use of this Website/PACNJ Asthma Treatment Plan and its content is at your own risk. The content is provided on an as is basis. The American Lung Association of the Mid-Atlantic (ALAM-A), the Pediatric/Adult Asthma Coalition of New Jersey and all affiliates disclaim all warranties, express or implied, statutory or otherwise, including but not limited to the implied warranties or merchantability, non-infringement of third parties rights, and fitness for a particular purpose. ALAM-A makes no representations or warranties about the accuracy, reliability, completeness, currency, or timeliness of the content. ALAM-A makes no warranty, representation or guaranty that the information will be uninterrupted or error free or that any defects can be corrected. In no event shall ALAM-A be liable for any damages (including, without limitation, incidental and consequential damages, personal injury/wrongful death, lost profits, or damages resulting from data or business interruption) resulting from the use or inability to use the content of this Asthma Treatment Plan whether based on warranty, contract, tort or any other legal theory, and whether or not ALAM-A is advised of the possibility of such damages. ALAM-A and its affiliates are not liable for any claim, whatsoever, caused by your use or misuse of the Asthma Treatment Plan, nor of this website. Sponsored by The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the American Lung Association in New Jersey. This publication was supported by a grant from the New Jersey Department of Health and Senior Services, with funds provided by the U.S. Centers for Disease Control and Prevention under Cooperative Agreement 5U59EH000491-04. Its content are solely the responsibility of the authors and do not necessarily represent the official views of the New Jersey Department of Health and Senior Services or the U.S. Centers for Disease Control and Prevention. Although this document has been funded wholly or in part by the United States Environmental Protection Agency under Agreement XA96296601-0 to the American Lung Association in New Jersey, it has not gone through the Agency s publications review process and therefore, may not necessarily reflect the views of the Agency and no official endorsement should be inferred. Information in this publication is not intended to diagnose health problems or take the place of medical advice. For asthma or any medical condition, seek medical advice from your child s or your health care professional.