Seizure Care Plan Form (2015) Page 2
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1
2Seizure care plan for Select Year
Student Name: __________________________________
Seizure Type: _________________________________________________ Average Length of seizure ___________________________
Frequency of seizures: __________________________________________ Possible Triggers: __________________________________
Any Warning and/or Behavior changes prior to seizure: __________________________________________________________________
Describe a typical seizure:
Usual time of day of seizure: ______________________________________ When was student’s last seizure: ______________________
Activity Restrictions after seizures: ___________________________________________________________________________________
List any special considerations, equipment, activity restrictions, treatments or special diet required at school related to seizure disorder:
Individual Considerations
Field Trip Procedures— Seizure medication should accompany student during any off campus activities.
Staff members on trip must be trained regarding Diastat and/or Clonazepam use and student health care plan (plan must be taken).
Other (specify): ________________________________________________________________________________________________________
Bus—Transportation should be alerted to student’s seizure disorder
Yes
No
This student carries seizure medication on the bus:
Yes
No
Seizure medication can be found in:
Backpack
On person
Other (specify) _________________________
Student will sit at front of the bus:
Yes
No
Other considerations:
EMERGENCY CONTACTS
1.
Relationship:
Day Phone:
Cell Phone:
2.
Relationship;
Day Phone:
Cell Phone:
3.
Relationship:
Day Phone:
Cell Phone:
4.
Relationship:
Day Phone:
Cell Phone:
I approve this Seizure Care Plan for my child.
I request this medication/VNS magnet to be given/used as ordered by the Health Care Provider.
I give consent to share information about my child’s seizure disorder with the district nurse, health assistant, teachers, principal, office staff,
guidance, bus driver/transportation, cafeteria workers, playground staff, and emergency staff on a “need to know basis”.
I give Health Services Staff permission to communicate with the medical office about this care plan / medication. I understand the medication will not
necessarily be given by the district nurse, but may be given by the health assistant or designated trained staff.
Parent/guardian must provide medication/equipment required to administer medication or provide special medical care.
All medication supplied must come in its original pharmacy-labeled container; and the container specifies the student’s name, name of prescriber, the
name of medication, the dose, the effective date, and the directions for administration.
Any changes in a medication require a new written authorization and corresponding change in the prescription label.
I understand that the medication maintained in the health room is not available after school hours, and that I need to provide additional rescue
medications for my child when involved in sports/activities after school hours.
Parent/Guardian Signature ______________________________________________________________ Date ______________________________
District Nurse Signature ________________________________________________________________ Date Reviewed ______________________
Fax Numbers:
Big Bend 262-662-1309
Clarendon 262-363-6289
Eagleville 262-594-5495
Prairie View 262-392-6312
Rolling Hills 262-363-6343
Section 262-363-6341
Park View 262-363-6320
Mukwonago High 262-363-6239
District Nurse Phone: 262-363-6292 x27515 Fax: 262-363-6320
Page 2 of 2
Revised 05/14/2015 by LAH
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