Asthma Action Plan Form (Page 2 of 2) in pdf

Asthma Action Plan Form Page 2

PERMISSION TO CARRY ASTHMA INHALERS/EPIPENS

TO BE COMPLETED BY THE PHYSICIAN: The above‐named student has been instructed in the proper use of their asthma

inhaler/emergency medication. The child’s well‐being is in jeopardy unless this medication is carried on his/her person. Therefore, I

request that he/she be permitted to carry the asthma inhaler/emergency medication at school. He/she understands the purpose,

appropriate method, and frequency of use of the asthma inhaler/emergency medication.

NAME OF MEDICATION: ______________________ PHYSICIAN’S SIGNATURE: _____________________ DATE: _________

TO BE COMPLETED BY THE PARENT/GUARDIAN: I permit my child to carry the above‐listed asthma inhaler/emergency medication

as ordered by his/her physician.

PARENT/GUARDIAN SIGNATURE: __________________________________________ DATE: ________________

TO BE COMPLETED BY SCHOOL NURSE: Kansas law now permits students to carry and use inhaled medications after demonstrating

appropriate use to school nurse. This student demonstrates knowledge / skill to carry and use the above listed asthma inhaler.

SCHOOL NURSE SIGNATURE: ______________________________________________ DATE: ________________

TO BE COMPLETED BY STUDENT: I have been instructed in the proper use of my medication and will take it as prescribed to me by

my physician.

STUDENT’S SIGNATURE: _________________________________________________ DATE: _________________

KS approval 07/15/09

Asthma Action Plan Form Page 2