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Emergency Action Plan (EAP)
Emergency Action Plan
Name_____________________________________________________________ D.O.B._____________________________
Address____________________________________________________________ Home phone_________________________
Parents/guardians __________________________________________________Grade______________________________
School ___________________________________________________________________________________________________
Healthcare provider(s)___________________________________________________________________________________
Insurance provider__________________________________ICD-10-CM__________________________________________
IEP Date_________________504 Date_________________EAP Date_________________EEP Date_________________
Medical Diagnosis:
If You See This: Do This:
Other:
Initiated by School Nurse ___________________________ Signature __________________________ Date ____________
Briefly define condition:
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