Student Asthma Action Card Page 2
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2Side 2 to be filled out by Parent/Guardian, Student, and School
STUDENT ASTHMA ACTION CARD (continued)
Student Name: ____
________________ School
Student D.O.B. __________
D
A
M
P
AILY
STHMA
ANAGEMENT
LAN
• Identify the things which start an asthma episode (If known, check each that applies to the student. These
should be excluded in the student’s environment as much as possible.)
□
□
□
Exercise
Chalk dust/dust
Food ______________
□
□
□
Strong odors or fumes
Carpets in the room
Molds
□
□
□
Respiratory infections
Animals _____________
Latex
□
□
□
Change in temperature
Pollens (Spring/Summer/Fall)
Other _____________
• List all asthma medications taken each day.
Name
Amount
When to Use
1. _________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________
C
S
I
OM M ENTS /
PECI AL
NSTRUCTI ONS
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
AUTHORIZATIONS
Parent/Guardian:
□ I want this plan to be implemented for my child in school.
□ I authorize my child to carry and self-administer asthma medications and I agree to release the school district
and school personnel from all claims of liability if my child suffers any adverse reactions from self-
administration and/or storage of asthma medications.
Yes
No
□ It is recommended that backup medication be stored with the school/ school nurse in case a student forgets or
loses inhaler or inhaler is empty. The school district is not responsible or liable if backup medication is not
provided to the school/ school nurse and student is without working medication when medication is needed.
Your signature gives permission for the nurse to contact and receive additional information from
your health care provider regarding the asthma condition and the prescribed medication.
Parent/Guardian Signature: _______________________________ Date: _______________________
Student Agreement:
□ I understand the signs and symptoms of asthma and when I need to use my asthma medication.
□ I agree to carry my medication with me at all times.
□ I will not share my or use my asthma medications for any other use than what it is prescribed for.
Student Signature: _______________________________________ Date: ______________________
□ Approved by School Nurse/School Principal
Back-up medication is stored at school
Yes
No
School Nurse/Principal Signature: _____________________________ Date: ______________________
Created by Asthma and Allergy Foundation of America, Alaska Chapter and the Alaska Asthma Coalition, October 2005. Revised 2012
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