School Asthma Action Plan Form Page 3
Download a blank fillable School Asthma Action Plan Form 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 School Asthma Action Plan Form 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
1
2
3DUBLIN UNIFIED SCHOOL DISTRICT
School Asthma Action Plan
Peak Flow Monitoring:
Name:_____________________________
Personal Best Peak Flow: ________________
Green Zone Plan (Indicates stability)
Peak flow reading is from __________to __________
Medicines_________________________________________________________________________
Yellow Zone Plan (Indicates trouble)
Peak flow reading is from _________ to __________
Call parent/guardian if student is in yellow or
red zone
Medicines_________________________________________________________________________
Red Zone Plan (Indicates emergency)
Peak flow reading is from _________to __________
Medicines_________________________________________________________________________
To Be Completed by Physician:
Seek emergency medical care if the student has difficulty breathing, with chest and neck retractions, is hunched
over, has trouble walking or talking, lips or fingernails are gray or blue.
Activate the emergency medical system: Call 911 and parent/guardian.
All Current Medications Prescribed:
Medication
Dosage
Time
Route
Prescribed Medications To Be Given At School: (if any)
Medication
Dosage
Time
Route
Self-Administration:
Physician and parent give authorization for the above named student to carry and self-administer
inhaler medication. Student and parent take responsibility for appropriate use of the inhaler as
prescribed and accept responsibility for student carrying and self-administering asthma inhaler
medication including keeping medication away from others. Self-administration of medication is not
recommended for elementary school students and will be considered on a case by case basis for all
students.
___Yes
___No
Note: A spacer is highly recommended for use with inhalers at school and at all times for proper
delivery of medication. (Please read backside of page before signing)
Parent authorizes the District Nurse to communicate with physician when necessary __ Yes __ No
Parent’s/guardian’s signature: __________________________________________ ________________
Date
Physician’s signature: ________________________________________________ _________________
Date
Reviewed by District Nurse (Signature): __________________________________ _________________
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business