Seizure Emergency Authorization Form For Medication/treatment
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1SEIZURE EMERGENCY AUTHORIZATION FOR MEDICATION/TREATMENT
School Board of Polk County
(Must be filled out completely and signed by physician/healthcare provider.)
_________________________________
___________
____
______________
Student’s Name
Birth Date
Grade
School Year
(
) _______
_________
Parent/Guardian: __________________________________________ Home ph. #
1
ph.#(2)
ph.#(3)_____________
Physician: ____________________________________________ Physician’s phone # _________________ Age diagnosed: ________________
Seizure Triggers: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Seizure Aura or Warning Signs (describe): ____________________________________________________________________________________
Seizure Type(s): _______________________________________________________ Length: _____________ Frequency: __________________
A “seizure emergency” for this student is described as: _________________________________________________________________________
Student’s Response after a seizure: __________________________________________________________________________________________
Student-specific Seizure Emergency Protocol (Physician and parent signature required below to administer medication):
____________________________________
Notify parent/guardian or emergency contact
Call 911 for transport to:
Administer Diazepam/ Diastat Rectal Gel _______mg: Give _______mg per rectum for seizures lasting more than
______minutes; or in clusters of more than __________seizures in 1 hour. Call 911 if the seizures do not stop
_______minutes after Diastat given or if child has problems breathing during or after a seizure.
Note: According to Polk County School Board policy, a licensed nurse is required for Diastat administration.
OR
Administer Clonazepam/Klonopin (orally disintegrating) tablets: _______mg: Give _______mg orally for seizures lasting
more than ______minutes; or in clusters of more than __________seizures in 1 hour. Call 911 if the seizures do not stop
_______minutes after given or if child has problems breathing during or after a seizure.
Vagus Nerve Stimulator? If yes, describe magnet use: _________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Call 911 if still seizing after ____swipes.
Wait ___ minutes between swipes.
Give _____swipes before any emergency
medication.
Special Considerations and Precautions (regarding school activities, sports, field trips, helmet use, etc.): _________________
____________________________________________________________________________________________________________
I hereby authorize the above named physician and Polk County Schools/Florida Department of Health in Polk County staff to reciprocally release
verbal, written, faxed, or electronic student health information regarding the above named child for the purpose of giving necessary medication
or treatment while at school. I understand Polk County School District protects and secures the privacy of student health information as
required by federal and state law and in all forms of records, including, but not limited to, those that are oral, written, faxed or electronic.
I request that my child be assisted in taking the medication or treatment described above at school by authorized persons as permitted by me
and my physician.
Parent/Guardian Signature: ________________________________________________________________________Date:______________
Physician’s/Mid-Level Practitioner’s Signature: _____________________________________________________ Date: ______________
School Health Registered Nurse Signature: ________________________________________________________ Date: ______________
911 Must Be Called When:
√ First known seizure
√ Any seizure lasting more than 5 minutes
√ Any seizure followed by another, without a period of
consciousness in between
√ A student with diabetes who has a seizure
Place Physician’s Office Stamp Here
√ A pregnant woman who has a seizure
√ Head injury during a seizure
√ Student has breathing difficulties or a seizure in water
√ Parent requests an ambulance be called
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