Seizure Action Plan For School Page 3
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PECIAL
EALTH
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EMERGENCY PLAN NON-MEDICAL STAFF
STUDENT NAME :
DOB:
TEACHER:
RM/GRADE :_________
PARENT/GUARDIAN:_______________________________PREFERRED HOSPITAL:________________________
HOME PHONE #:________________
WORK #:___________________ CELL #:_________________________
EMERGENCY CONTACT:____________________________ PHONE:_______________OTHER PHONE:_________
PHYSICIAN:__________________________ PHYSICIAN TEL:_______________ PHYSICIAN FAX:______________
STUDENT-SPECIFIC EMERGENCIES
IF YOU SEE THIS
DO THIS
IF AN EMERGENCY OCCURS:
1.
If the emergency is life-threatening, immediately call 911.
2.
Stay with student or designate another adult to do so.
3.
Call or designate someone to call the principal and/or school nurse.
a.
State who you are.
b.
State where you are.
c.
State problem.
DOCUMENTATION OF STAFF TRAINING
DATE:
TRAINED BY:
STAFF NAME:
__________
_______________________
______________________________
__________
________________________
______________________________
__________
________________________
______________________________
__________
________________________
______________________________
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