Seizure Health Plan And Emergency Action Plan
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2SEIZURE HEALTH PLAN and EMERGENCY ACTION PLAN
Use this form for Daily and Emergency Medication for students with Seizures
Student ________________________________________________________ Birth date __________________________
School _____________________________________ Grade ______________ School Year ________________________
Parent/Guardian 1: ______________________________
Parent/Guardian 2: ________________________________
Daytime Phone (_____) ___________________________
Daytime Phone (_____) _____________________________
Cell (_____) ____________________________________
Cell (_____) _______________________________________
Email: ________________________________________
Email: ____________________________________________
Neurologist _____________________________________________
Phone Number: _____________________________
Authorization expires at the end of the school year or following the summer school session.
Parent/Guardian Consent:
I give permission for my son/daughter to receive the medication listed below. I also give permission for school district
personnel to contact the health care provider, if necessary, to clarify orders regarding this medication. I agree to notify the
school with changes to this seizure care plan.
I understand that it is my responsibility to:
•
Transport the medication to school in the original container/packaging or a pharmacy-labeled container
•
Replace the supply of medication when needed
•
Pick up medication or direct staff to discard remaining medication upon discontinuation or at the end of the school
year
Parent/Guardian Signature ________________________________________________Date _____________________
Seizure Medication
(please list ALL medications student takes for seizures)
You must obtain a Healthcare Provider Signature for all medication needed at school
Daily Medication
Medication
Dose
Route
Frequency
Side Effects
Emergency Medication
Medication
Dose
Route
Frequency
Side Effects
Directions for Emergency Use
SEIZURE FIRST AID:
Stay calm, note/track time & record details of seizure on record
Keep child safe, protect head and turn child on his/her side
Keep airway open and watch breathing
Do NOT restrain child or put anything in his/her mouth
Do NOT leave child alone – send other staff for help
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