Asthma Action Card Form Page 2
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1
2A
A
C
STHMA
CTION
ARD
D
A
M
P
T
P
/G
S
Side 2, Continued:
AILY
STHMA
ANAGEMENT
LAN
O BE COMPLETED BY
ARENT
UARDIAN AND
TUDENT
Student Name: ________________________________________ Birthdate ______________________
•
Identify the things which start an asthma episode (if known) Check all that apply. These should be excluded from the
student’s environment as much as possible.
Exercise
Chalkdust/ Dust
Food ___________________
Strong Odors or Fumes
Carpets in Room
Molds
Respiratory Infections
Animals _______________
Latex
Change in Temperature
Pollens Spring/Summer/Fall
Other:
•
List all asthma medications taken each day (including at home).
Name
Amount
When to Use
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________
•
Comments and Special Instructions
________________________________________________________________________________________________________
_____________________________________________________________________________________
A
:
UTHORIZATIONS
P
/G
:
ARENT
UARDIAN
I want this plan to be implemented for my child at school
I authorize my child to carry and self-administer asthma medications and I agree to release ASD and school personnel from all
claims of liability if my child suffers any adverse reactions from self-administration and/or storage of asthma medication.
Yes
No
It is recommended that backup medication be stored with the school/school Nurse in case a student forgets or loses inhaler or
inhaler is empty. The school district is not responsible or liable if backup medication is not provided to the school/school nurse
and student is without working medication when medication is needed.
If school nurse is unavailable, I authorize delegation of emergency medications to staff trained by ASD nurse.
Your signature gives permission for the nurse to contact and receive additional information from your healthcare provider regarding
the asthma condition and the prescribed medication regimen.
Parent/Guardian Signature _____________________________________ Date ________________________________
S
A
:
TUDENT
GREEMENT
I understand the signs and symptoms of asthma and when I need to use my asthma medication.
I agree to carry my medications with me at all times.
I will not share them or use my asthma medications for any other use than what it is meant for.
Student Signature______________________________________________ Date _______________________________
S
A
:
CHOOL
GREEMENT
Approved by School Nurse/School Principal. Back up medication is stored at school
Yes
No
Trained Staff Name
Title
Location/Rm #
Trained by (RN only)
School Nurse/School Principal Signature _______________________________
Date ________________________
Anchorage School District, Nursing & Health Services
Page 2 of 2
NUR # 0505
Revised 6/2013
Created by Asthma and Allergy Foundation of America, Alaska Chapter and the Alaska Asthma Coalition, October 2005.
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