Seizure Action Plan Template
Download a blank fillable Seizure Action Plan Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Seizure Action Plan Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Seizure Action Plan
Effective Date
This student is being treated for a seizure disorder. The information below should assist you if a seizure occurs during
school hours.
Student’s Name
Date of Birth
Parent/Guardian
Phone
Cell
Other Emergency Contact
Phone
Cell
Treating Physician
Phone
Significant Medical History
Seizure Information
Seizure Type
Length
Frequency
Description
Seizure triggers or warning signs:
Student’s response after a seizure:
Basic Seizure First Aid
Basic First Aid: Care & Comfort
•
Stay calm & track time
Please describe basic first aid procedures:
•
Keep child safe
•
Do not restrain
•
Do not put anything in mouth
❒
❒
Does student need to leave the classroom after a seizure?
Yes
No
•
Stay with child until fully conscious
•
Record seizure in log
If YES, describe process for returning student to classroom:
For tonic-clonic seizure:
•
Protect head
•
Keep airway open/watch breathing
Emergency Response
•
Turn child on side
A “seizure emergency” for
Seizure Emergency Protocol
A seizure is generally
this student is defined as:
(Check all that apply and clarify below)
considered an emergency when:
•
Convulsive (tonic-clonic) seizure lasts
❒
Contact school nurse at __________________________
longer than 5 minutes
❒
Call 911 for transport to __________________________
•
Student has repeated seizures without
❒
Notify parent or emergency contact
regaining consciousness
•
❒
Student is injured or has diabetes
Administer emergency medications as indicated below
•
Student has a first-time seizure
❒
Notify doctor
•
Student has breathing difficulties
❒
Other ________________________________________
•
Student has a seizure in water
Treatment Protocol During School Hours (include daily and emergency medications)
Emerg.
Dosage &
Med. ✓ ✓ ✓ ✓ ✓
Medication
Time of Day Given
Common Side Effects & Special Instructions
❒
❒
Does student have a Vagus Nerve Stimulator?
Yes
No
If YES, describe magnet use:
Special Considerations and Precautions (regarding school activities, sports, trips, etc.)
Describe any special considerations or precautions:
Physician Signature ___________________________________________________ Date _________________________________
Parent/Guardian Signature _____________________________________________ Date _________________________________
DPC772
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business