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Jefferson County Public Schools Health Services

Primary Care Provider (PCP) Authorization: G-Tube/Swallowing/Feeding Disorders (Side Two)

2012-2013 School Year

Student Name: __________________________Date of Birth: __________________School: __________________________________

EMERGENCY PLAN OF ACTION

1. If breathing stops or other signs of distress: Call EMS 9-911.

2. Notify school personnel trained in CPR/first aid respond and initiate CPR if needed prior to EMS arrival.

3. Notify parent/guardian or emergency contact immediately.

4. School personnel cannot forcefully flush or replace a tube into the stomach. However, a trained nurse (APRN, RN, or LPN), if available may replace

tube. If nurse is unavailable or no replacement g-tube is available, then school staff will place gauze and tape over the site if tube becomes dislodged.

5. The parent/guardian will be notified immediately if a tube becomes clogged or dislodged. If unable to reach the parent/guardian within 30 minutes of

tube becoming dislodged AND/OR they are unable to get to school within 1 hour of tube becoming dislodged, call EMS 9-911.

6. If EMS is called the student must be transported via EMS to emergency facility, or parent/guardian must sign release with EMS and then

parent/guardian assumes responsibility for student. The student may not return to school that day.

7. When student is transported via EMS, JCPS staff must ride with student unless parent and/or emergency contact accompanies them.

8. If student requires medical treatment while on the bus, the driver will contact EMS.

9. Other (Specify): __________________________________________________________________________________________

Form must be signed by health care provider and parent/guardian. If you have any questions please call (502) 485-3387 or

Fax: (502) 485-3670.

Please return to: Jefferson County Public Schools, Health Services, Lam Building, 4309 Bishop Lane, Louisville, KY 40218

_____________________________

_________________________

___________________________________________

Printed Name of MD, APRN, or PA

Address

Telephone No.

_____________________________

_________________________

____________________

Signature of MD, APRN, or PA

Fax No.

Date

Note to parent/guardian: Signing this form shall release the Jefferson County Board of Education and its employees from liability of any nature that might result from

this plan of action. This form shall not relieve the liability of the school or its employees for their own negligence. Also, I hereby give permission for the healthcare

provider completing and signing this form to verify this information with JCPS and to consult with JCPS staff regarding this information. I also acknowledge that

feedings and the emergency plan of action will most likely be administered by trained, unlicensed JCPS personnel. I acknowledge and agree when I authorize my child

to attend a school sponsored field trip these medications and/or health services may also be provided by a licensed volunteer.

__________________________________

___________________

______________________

Signature of Parent/Guardian

Telephone No.

Date

**Parent/Guardian signature required only for INITIAL 2012-2013 PCP form. Parent/Guardian signature not required for updated 2012-2013 PCP forms.

__________________________________ ___________________ _____________________

Emergency Contact

Telephone No.

Relationship