Emergency Action Plan

Student:_Jane Doe__________________ Date:_5/17/2019______

Grade:__3rd________ Teacher:_Mr. Smith__________________ School:_A Elementary_______

Summary of Medical Condition:

_Moderate Persistent Asthma- Asthma is a chronic respiratory disease that can cause wheezing, cough, and
shortness of breath. Albuterol can be used to relieve these symptoms. Jane’s albuterol inhaler will be kept in the
nurse’s office. ________________________________________________

If you see this: Do this:

Jane coughing, wheezing, or complaining Send Jane to the nurse with a partner so that Jane can
of shortness of breath receive 2 puffs of her albuterol. DO NOT send Jane
alone.
Jane struggling to breath. Symptoms may Have Jane sit down. Call the nurse immediately. Jane
include: rapid breathing, difficulty needs 4 puffs of her albuterol inhaler now, and may need
speaking, Jane physically working to to go to the hospital. DO NOT leave Jane alone.
breath, Jane’s nostrils flaring with each
breath, or Jane turning pale or blue.
In an Emergency:
 Stay with the student
 Call or designate someone to call the nurse:
o State who you are
o State where you are
o State the problem
 The school nurse will assess the child/situation and decide whether the emergency plan should be
implemented.
 If the school nurse is unavailable, the following staff members are trained to deal with an
emergency and initiate the emergency plan:
_Jane and the school secretary_________________________________________________________
Contact Information:

Mother/Guardian: work:(333)333-3333____ home: (111)111-1111_______ cell:(222)222-222___

Father/Guardian: work(444)444-4444____ home:(555)555-5555___ cell:(777)777-7777____

Parent Signature__MOM_____________________________________ Date:5/17/19______

Physician Signature_DOCTOR___________________________________ Date: 5/17/19___

School Nurse Signature__NURSE_______________________________ Date: 5/17/19____

The completed “Emergency Action Plan” will be on file with the school nurse and a copy will be given to your child’s teachers, as
necessary.