Individual Health Care Plan Form printable pdf download

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Individual Health Care Plan Form

Plan must be renewed annually or when child’s condition changes

Check all that apply….

Plan was created by:

Plan is maintained by:

__ Parent

__ Director

__ Doctor or Licensed Practitioner

__ Assistant Director

__ Program’s Health Care Consultant

__ Child’s Educator

__ Older school age child (9+ yrs. of age)

__ Other: ___________________________

__ Other: __________________________

Name of child:

Date:

Any change to the child’s Health Care Plan?

YES (indicate changes below)

NO (updated physician/parental signatures required)

Name of chronic health care condition:

Description of chronic health care condition:

Symptoms:

Medical treatment necessary while at the program:

Potential side effects of treatment:

Potential consequences if treatment is not administered:

Name of educators that received training addressing the medical condition:

Person who trained the educator (child’s Health Care Practitioner, child’s parent, program’s Health Care

Consultant):

Name of Licensed Health Care Practitioner (please print):_______________________________________________

Licensed Health Care Practitioner authorization:_____________________________________ Date:_____________

Parental/Guardian consent: _____________________________________________________ Date:_____________

For Older Children ONLY (9+ years of age)

With written parental consent and authorization of a licensed health care practitioner, this Individual Health Care Plan permits

older school age children to carry their own inhaler and/or epinephrine auto-injector and use them as needed without the direct

supervision of an educator.

The educator is aware of the contents and requirements of the child’s Individual Health Care Plan specifying how the inhaler or

epinephrine auto-injector will be kept secure from access by other children in the program. Whenever an Individual Health Care

Plan provides for a child to carry his or her own medication, the licensee must maintain on-site a back-up supply of the medication

for use as needed.

Age of child: _______________

Date of birth: _____________________ Back-up medication received? YES

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SG/LG/SAIndHealthCarePlan20101029

Parent signature: _______________________________________________ Date: ________________________________

Administrator’s signature: ________________________________________ Date: ________________________________

Individual Health Care Plan Form

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