Life-Threatening Medical Condition Emergency Transportation Form
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1APPENDIX A
LIFE-THREATENING MEDICAL CONDITION EMERGENCY
TRANSPORTATION FORM
Student Name:
STUDENT’S
Student #:
PHOTO
Address:
HERE
Phone #:
School:
Grade:
LIFE-THREATENING MEDICAL CONDITION:
Life-Threatening Allergy/Anaphylaxis:
Auto Injector can be found:
(Please indicate location of Epinephrine Auto Injector on pupil)
Epilepsy
Asthma
Heart Condition
Pace Maker
Diabetes
Other (specify):
Consent for administration of medication form on file at school:
YES
NO
(Principal’s Signature)
(Date)
1.
Use of this form is to be limited ONLY to pupils with life-threatening medical conditions that may require the emergency
administration of an epinephrine auto-injector, or other emergency medical attention, who ride a school bus or use small
vehicle transportation.
2.
This form shall contain a clear and recent photograph of the pupil.
3.
Schools are to forward (3) copies of this form (one original form with original photograph and Principal signature, and no
less than two photocopies of the completed form with clear photographs) to the Ottawa Student Transportation
Authority. Forms are NOT to be given directly to the driver/transportation provider by parents/guardians or school staff.
TRANSPORTATION INFORMATION:
Pickup Bus:
(ROUTE #)
Drop Off Bus:
(ROUTE #)
DISPATCH PROCEDURES:
1. Obtain exact location and time of administration.
2. Call 911.
3. Call Principal of____________________ School at 613-
(phone number) or cellular at ______________
4. Maintain radio contact.
5. Call OSTA General Manager (or designate) at 613-224-8800 ext. 2580
Information contained on this form is confidential when complete.
Page 1 of 1
Distribution: 1. OSTA
2. OSTA to provide to operator
OSTA /OCT09
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