Asthma Action Plan (Page 2 of 2) in pdf

Students will be permitted to possess and use Asthma Inhalers in school with permission from their

physician, parents, and the school nurse only to permit immediate access to this emergency medication

in order to prevent a life-threatening crisis and not for the convenience of daily administration. Students

must report to the nurse’s office when routine daily administration is require

I have instructed ______________________ in the proper way to use his/her Asthma Inhaler and it

is my professional opinion that this student should be allowed to carry and use this medication by

him/herself.

It is my professional opinion that _____________________should not carry his/her Asthma

Inhaler. This medication will be kept in the nurse’s office and administered by the nurse.

Physician’s Signature ___________________________________________

Date

_______________

Physician’s Name Printed

________________________________________________________________________

Name of Practice _____________________________________Office Phone # _________________

To carry and self administer Asthma Inhaler medication, the student must demonstrate to the school

nurse the capability for proper self-administration and responsible behavior in assuring that medication

availability is restricted from other students. The student must notify the school nurse immediately

following each use of an Asthma Inhaler. The medication will be confiscated and student privileges lost

if school policies are abused or ignored.

As the parent/guardian of the above named student, I relieve the school district and its employees of any

responsibility for the benefits or consequences of the above listed medication when it is physician

prescribed and parent/guardian authorized. I further acknowledge that the school bears no responsibility

for ensuring that the medication is taken. I am aware that this student must notify the school nurse

immediately following each use of the above prescribed medication, and that the medication will be

confiscated and student privileges lost if school policies are abused or ignored.

I give permission to the doctor, nurse, health plan, and other health care providers to share information

about my child’s asthma to help improve the health of my child.

Parent/Guardian Signature _________________________________________ Date _____________

To carry and self administer Asthma Inhaler medication I agree to be solely responsible for my

Asthma Inhaler and to follow the directions for its use as ordered by my physician, and the district’s

medication policy. I am aware that ignoring district policies or abusing this privilege will result in the

confiscation of my inhaler and loss of my privilege to self administer my medication. I will demonstrate

responsible behavior at all times by assuring that my prescribed medication is not shared with, or in any

way made available to, other students.

Student’s Signature ________________________________________________ Date _____________

Approved 4/8/11

Asthma Action Plan Page 2