Seizure Disorder Health Care Plan And Medication Administration Authorization Form (Page 2 of 3) in pdf

Page 2 of 3

PRINCE GEORGE COUNTY PUBLIC SCHOOLS

Seizure Disorder Health Care Plan and Medication Administration Authorization

♥ TO BE COMPLETED BY PARENT / GUARDIAN ♥

Student’s Name: _________________________________________ School: _______________________ Teacher: _______________

Age of onset of seizures: ____________ Date of last seizure: ____________________ Time/length of seizure:___________________

Describe your child’s seizure:_____________________________________________________________________________________

_____________________________________________________________________________________________________________

How many times has your child been seen in the emergency room for seizures in the last year? _________________________________

Date your child was last seen by a physician for evaluation/follow-up for seizure disorder:_____________________________________

List any known triggers for seizure activity:__________________________________________________________________________

_____________________________________________________________________________________________________________

List any warning signs and/or behavioral changes that may indicate a seizure is about to occur:_________________________________

_____________________________________________________________________________________________________________

Plan for field trips:

Parent will attend: ________YES

________NO

In the absence of the parent, the principal’s designee who has been trained in administration of medication and measures to follow in the

event of a seizure will attend the field trip to provide care and administer medication (if prescribed).

Other:

Plan for transportation to and from school:

The Transportation Department will be informed of student’s seizure condition and has radio communication with bus drivers.

Other:

Plan for instructing administration and instructional staff:

School nurse will share seizure disorder health care plan information with administration and instructional staff.

A registered nurse will provide training in administration of medication (if prescribed) and measures to follow in the event of a seizure

to unlicensed personnel designated by the principal to provide care and administer medication in the absence of the nurse.

Other:

Plan for notifying substitutes:

Teacher is responsible to share seizure disorder health care plan information with substitutes.

Additional Instructions:

EMERGENCY CONTACTS: Name/Relationship

Phone Number(s)

a. __________________________________________ 1.) ____________________________ 2.) _____________________________

b. __________________________________________ 1.) ____________________________ 2.) _____________________________

c. __________________________________________ 1.) ____________________________ 2.) _____________________________

HSM 0005-0809

Seizure Disorder Health Care Plan And Medication Administration Authorization Form Page 2