New

ASTHMA ACTION PLAN & AUTHORIZATION FOR MEDICATION
TO BE COMPLETED BY PARENT:
Child’s Name
Name of Physician/Nurse Practitioner/Physician Assistant What triggers your child’s asthma attack: (Check all that apply)
 Illness
_________________________________________ Allergies:  Cat  Dog  Dust  Mold  Pollen  Other ________________________________________
Describe the symptoms your child experiences before or during an asthma episode: (Check all that apply)
 Cough
 Other ________________________________________
TO BE COMPLETED BY HEALTH CARE PROVIDER:
The child’s asthma is:  Intermittent  Mild Persistent  Moderate Persistent  Severe Persistent  Exercise-Induced
Peak Flow
Symptoms OR Monitoring
Treatment
Controllers & Relievers
 Inhaled Corticosteroid ________
Personal
Leukotriene Modifier:
 Other__________________
Relievers
 2 puffs or 1 nebulizer
nebulizer treatment) every treatment 5 min. before
4-6 hrs. as needed
physical activity
______
1.  Continue daily controller medications 2.  Give albuterol 2-6 puffs (1 min. between puffs) with spacer or 1 nebulizer treatment, wait 3.  If no improvement, repeat 2-6 puffs or 1 nebulizer treatment, wait 20 min. Call parent and/or
If no improvement, CALL 911
If child returns to Green Zone:
 Continue to give albuterol 2 puffs every 4 hours for 1 to 2 more days  No physical exercise  Physical exercise as tolerated i.e. PE & recess at school EMERGENCY!
Give albuterol (2-6 puffs (with spacer) or 1 nebulizer treatment NOW! May repeat
once after 20 min.
If there is no improvement, call parent and/or 911.
<________
Call 911 immediately if:
• Child is struggling to breathe and there is no improvement 20 minutes after taking albuterol • Child has trouble talking or walking • Child has lips or fingernails that are gray or blue • Child’s chest or neck is pulling in with breathing PATIENT/STUDENT INSTRUCTIONS:
 Student has been instructed in the proper use of all his/her asthma medications, and in my opinion, the student can carry and use his/her inhaler at school
 Student is to notify his/her designated school health officials after using inhaler per school protocol
 Student needs supervision or assistance to use his/her inhaler  Student shall NOT be able to carry his/her inhaler while at school

Valid for current school
HEALTH CARE PROVIDER SIGNATURE
PLEASE PRINT PROVIDER’S NAME
I give permission for school personnel to follow this plan, administer medication and care for my child and contact my physician if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Asthma Management Plan for my child. PARENT SIGNATURE
Virginia Asthma Coalition
cc: principal____ office staff____ librarian____ cafeteria mgr.____ bus driver/transportation____ Coach/PE____ teachers____ revision 3/07 RELEASE AND ACKNOWLEDGEMENT AGREEMENT BY PARENTS OF CIVIL IMMUNITY FOR SCHOOL BOARDS AND SCHOOL EMPLOYEES I/WE UNDERSTAND THAT the Code of Virginia §8.01-226.5:1 grants civil immunity for school boards and school employees who, in good faith, without compensation, supervise the self-administration of inhaled asthma medications by a student. The Prince William County School Board and Prince William County school employees shall not be liable for any civil damages for acts or omissions resulting from supervising the self-administration of inhaled asthma medications by students. IT IS FURTHER AGREED AND UNDERSTOOD that it is my/our responsibility to ensure that the medicine is properly labeled as to its nature and the means of administration. It is also my/our responsibility to ensure that the medicine is fresh and adequately stored, and that an adequate supply is available at school. If the dosage changes or the medication is to be stopped prior to the time noted in the prescription, it is my/our responsibility to communicate the change clearly, in writing, to school staff. I/WE CONSENT to the above conditions and acknowledge that Prince William County Public Schools is acting as my/our agent in supervising self-administration of asthma medication by my/our child. I/WE FURTHER STATE that this release and acknowledgement agreement has been carefully read and I/WE know of the contents thereof and have signed the same by my/our own free act. Name of Parent/Guardian (Printed) Signature (This agreement must be signed and returned to the building principal before medication can be administered.)

Source: http://huddle.battlefield.groupfusion.net/modules/groups/homepagefiles/cms/5981/File/R757-5_form.pdf