SEIZURE ACTION PLAN FOR SCHOOL
Student Name______________________________D.O.B.____________ ID #
Student
Picture
School
Teacher_______________
_
Physician
Phone:
EMERGENCY CONTACTS
Name
Relationship
Home #
Work #
Cell #
1.___________________________________________________________________________________
2.___________________________________________________________________________________
3.___________________________________________________________________________________
Type of seizure:
What does the seizure look like and how long does it usually last?
____
____
Possible triggers that should be avoided:
____
____
Does student need any special activity adaptations/protective equipment (e.g., helmet) at school?
_____ No _____ Yes (explain)
____
____
Is student allowed to participate in physical education and other activities? _____ No _____ Yes (explain)
No _____ Yes (List below the medications needed)
ARE MEDICATIONS NEEDED TO CONTROL THE SEIZURES? _____
MEDICATIONS
AMOUNT TAKEN
HOW OFTEN AND FOR WHAT SIGNS
1.
2.
3.
List medication needed at school (name, dosage/route, and frequency)
Possible side effects that must be reported to parent or physician:
IF GENERALIZED SEIZURE OCCURS:
1.
If falling, assist student to floor, turn to side.
2.
Loosen clothing at neck and waist; protect head from injury.
3.
Clear away furniture and other objects from area.
4.
Have another classroom adult direct students away from area.
5.
T IME THE SEIZURE.
6.
Allow seizure to run its course; DO NOT restrain or insert anything into student’s
mouth. Do not try to stop purposeless behavior.
7.
During a general or grand mal seizure expect to see pale or bluish discoloration
of
the skin or lips. Expect to hear noisy breathing.