Student Seizure Disorder Health Care Plan Template

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Board Policy JHCD-R3:
Pulaski County Schools
Student Seizure Disorder Health Care Plan
Student name: _________________________________________________DOB: __________________________
The following is to be completed by physician:
______This student has been diagnosed with a Seizure disorder.
Comments/Special instructions specific to this student: _________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
**Any medication needed by student at school will require that a Medication Authorization form be
completed and signed by a physician and parent/guardian.
Signs of Seizure activity include: staring/visual disturbance jerks, unusual smell/tastes, involuntary
rigidity/jerking/shaking, becomes unresponsive, behavior changes, shallow breathing, and bluish skin,
possible loss of bowel/bladder control.
These signs indicate the need for the following care:
Protect head from injury
Turn student on his/her side to keep airway clear
Clear area and provide privacy
Loosen collar if needed
Do not restrain student
Do not move student if injury has occurred
Remain with the student
Document seizure activity, include date, time, duration, objective facts about seizure behavior.
Monitor breathing and, if necessary, begin rescue breathing after muscle jerks subside.
Call 911-if seizure last more than five minutes, if multiple seizures occur; student is pregnant,
injured, or diabetic.
Notify principal and call parents/guardian
Record and send with person transporting documentation of seizure activity and other significant data,
along with a copy of this plan.
Please list any special considerations/activity restrictions/treatments related to student’s seizure disorder:
Please list any special precautions for field trips/transportation to and from school: ___________________________
_____________________________________________________________________________________________
This plan is in accordance with the student’s medical management and is to be followed at school.
Physician signature: ____________________________________________________Date: ____________________

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