SEIZURE EMERGENCY CARE PLAN
Date of Plan: __________. This plan is valid for the current school year: ____________________
The student’s primary care provider/health care team, including the parents/guardian, should complete this
plan. It will be reviewed with the relevant school staff and copies will be kept in a place that can be accessed
easily by the school nurse, trained personnel, and other authorized personnel.
Student Name: ________________________________Grade: ________
Current Medications: _______________________________
Type of Seizures: _____________________ How often do they occur? ___________________
Describe Seizure Activity (include symptoms before, during and after seizure):
School Restrictions: ___________________
Protocol for seizure:
Keep calm and remain with student. Ease student to the floor. If needed, loosen any clothing
around the neck area and protect him/her from any sharp or hard objects in the area.
Do not force anything into his or her mouth.
Roll student on his/her side to drain secretions and insure that the student is able to breathe.
Observe and record the nature and length of the seizure. After the seizure has subsided,
continue to monitor airway and breathing. Allow the student to rest. (Documentation chart
located on back of this form).
Call parents to notify them of seizure after it has ceased and the student is aroused.
If seizure last longer than 5 minutes:
Page first responder team or call the school nurse at Ext. 105 for assistance.
Administer rescue medication: __________________________________ for seizures lasting
longer than 5 minutes as prescribed by the physician. Monitor breathing rate and color of
student. (Persons administering medication MUST have training and clearance prior to
When 911 are called, remain with student until paramedics or other appropriate assistance arrives.
If student is to go to the hospital with paramedics, a school staff member is to accompany the
student to the hospital with a copy of the health enrollment card and remain with the student until
the parents arrive.
Parent/Guardian: _________________________________________________ Date: _______
Physician/Health Care Provider: _____________________________________ Date: _______