Asthma Action Plan (medication administration)

Information & Form

 

 

Click on the link below to DOWNLOAD FORM

 

 

 

For students who might need Asthma medication, a Healthcare Provider must fill out the Asthma Action Plan/medication administration STATE form, sign & stamp.  The Parent/Guardian must also sign this form.

 

This form enables the School Nurse and staff members to assist students in an Asthma attack or episode.  

 

 

 

Students cannot carry medications on them except for an Inhaler, EpiPen, and Diabetic supplies if there is an updated (yearly) consent form on file in the health office indicating self-carry signed, stamped, by the Healthcare Provider and Parent/Guardian. 

 

All other medications such as Tylenol, Advil, migraine medications, ADHD medications must be locked up in the health office and can only be administered by the School Nurse if the updated (yearly) consent form is on file in the health office.

 

 

 

The Healthcare Provider is not required to fill out any other form for Asthma administration.

 

 

 

If your child does not need Asthma medications, disregard this form.

 

 

 

The Asthma Action Plan/medication administration form is valid for one school year, ONLY!  

 

 

 

Asthma Action Plan Instructions for Parent/Guardian

https://claytonps.org/wp-content/uploads/Website-mail_STATE_asthma-action-plan_form_p2_scanned.pdf

 

 

Asthma Action Plan for Healthcare Providers to fill out and Parent/Guardian to sign at bottom  

https://claytonps.org/wp-content/uploads/Website-mail_STATE_asthma-action-plan_form_p1_scanned.pdf

 

 

 

 

 

 

 

*Scroll to bottom and click for Spanish or other translation! 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Updated 9/29/2020