Plano Independent School District Asthma Action Plan printable pdf download

PLANO INDEPENDENT SCHOOL DISTRICT

ASTHMA ACTION PLAN

This plan is in accordance with new legislation, HB1688, which passed during the 2001 Texas Legislative

Session. This bill allows students to self-administer asthma medications while at school or school functions

with permission from physicians and parents.

(To be completed at the beginning of each school year and kept on file with the school nurse)

Student’s Name:

DOB:

Father: ________________________ H: _____________ W: _____________ Cell: _______________

Mother: ________________________ H: _____________ W: _____________ Cell: _______________

Physician student sees for asthma: ___________________________________

Phone: _____________

Other Physician: _________________________________________________

Phone: _____________

SELF-ADMINISTRATION OF ASTHMA MEDICATIONS (To be filled out by physician)

Physician Please Check one:

It is my professional opinion that ____________________________ (student’s name) should NOT be

allowed to carry and self-administer any of his/her asthma medications while on school property or at

school related events.

I have instructed _________________(student’s name) in the proper way to use his/her medications. It is

my professional opinion that _________________(student’s name) should be allowed to carry and self-

administer the following medications while on school property or at school-related events.

A. Bronchodilator (quick-relief medication) - must have pharmacy label on actual plastic inhaler.

Name: ______________________________________ Dosage: ________________________

Purpose: _____________________________________________________________________

When to use: __________________________________________________________________

Can be repeated for severe breathing difficulty _______ times ________ minutes apart.

Call 911 or EMS if minimal or no improvement.

B. Other Medications - all other medications must have a pharmacy label.

Name: ______________________________________ Dosage: ________________________

Purpose: _____________________________________________________________________

When to use: __________________________________________________________________

Additional instructions: _________________________________________________________

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Physician’s Signature

Phone

Date ______

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I agree with the recommendations of my child’s physician as noted above and have informed my child that

he/she may carry his/her asthma medications while on school property or at school-related events.

Parent/Guardian’s Signature _____________________________ Date _______________________

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Plano Independent School District Asthma Action Plan