Fillable INDIVIDUALIZED HEALTHCARE PLAN FOR STUDENTS WITH ASTHMA 2021-2022

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INDIVIDUALIZED HEALTHCARE PLAN FOR STUDENTS WITH ASTHMA 2021-2022

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Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 101b
INDIVIDUALIZED HEALTHCARE PLAN FOR STUDENTS WITH ASTHMA
2021-2022 SCHOOL YEAR
To be completed by the Parent:
School: Grade:
Students Name: Age:
Student needs to avoid:
Reaction(s) student has:
Self-Carry permission from physician: NO YES; Student will carry inhaler (where): _______________________________
If yes, (1) the prescription medicine has been prescribed for that student as indicated by the prescription label on the medicine; (2) the
student has demonstrated to the student’s physician or other licensed health care provider and the school nurse, if available, the skill level
necessary to self-administer the prescription medication, including the use of any device required to administer the medication; and (3)
the self-administration is done in compliance with the prescription or written instructions from the student’s physician or other licensed
health care provider. In addition, as the parent, I am providing written authorization for my student to self-administer the prescription
medicine while on property or at a school-related event or activity. I understand that such self-administration must be done in compliance
with the prescription or written instruction of the student’s physician. Additionally, I have provided a written statement from my student’s
physician or other licensed health care provider, signed by the physician or provider that states:
1. That the student has asthma and is capable of self-administering the prescription medicine;
2. The name and purpose of the medicine;
3. The prescribed dosage of the medicine;
4. The times at which or circumstances under which the medicine may be administered; and
5. The period for which the medicine is prescribed
Medication and inhaler at school location for medication will be stored: (required):
Parent/Guardian Signature: Date:
EMERGENCY CONTACTS
OTHER EMERGENCY CONTACTS
PARENT/GUARDIAN:_____________________________________________________
PHONE:_________________________________________________________________
DOCTOR: _______________________________________________________________
PHONE:_________________________________________________________________
NAME:______________________________________________________________________
PHONE:_____________________________________________________________________
NAME:______________________________________________________________________
PHONE:_____________________________________________________________________
_______________________________ (Student’s Name) has asthma as mentioned in the Individualized Healthcare Plan from the
physician. I have provided to the school the physician’s medication permission and instructions. I am requesting these instructions be
carried out by the school. I have instructed my child about his/her asthma and how to avoid exposure to the triggers, care to take if
exposure occurs and tell an adult immediately if they are having a reaction. I will provide the medication with a proper pharmacy label
and be aware of the expiration date to replace the medication. I hereby request the medication specified by the physician be given to the
above named student, and it may be administered by medical or non-medical personnel. I understand 911 may be called if symptoms
worsen.
Such agreement by the school is adequate consideration of my agreements contained herein. In consideration for the school agreeing to
allow the medication to be given to the student as requested herein, I agree to indemnify and hold harmless the Archdiocese of Galveston-
Houston, its servants, agents, any employees, including, but not limited to the parish, the school, the principal, and the individuals giving
the medication, of and from any and all claims, demands, or causes of action arising out of or in any way connected with the giving of the
medication or failing to give the medication to the student. Further, for said consideration, I, on behalf of myself and the other parent of
the student, hereby release and waive any and all claims, demands, or causes of action against the Archdiocese of Galveston-Houston, its
agents, servants, or employees, including, but not limited to the parish, the school, the principal, and the individual giving or failing to
give the medication.
Parent/Guardian Signature: Date: ________________
To be completed by School:
School Nurse/Health Coordinator Signature: Date:
Principal Signature: Date:
Before & After Program Coordinator Signature: Date:
Teacher notification provided by: Date:
School staff may be notified of the student’s health condition and the treatment plan in case of an emergency
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Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 101c
INDIVIDUALIZED HEALTHCARE PLAN FOR STUDENTS WITH ASTHMA
2021-2022 SCHOOL YEAR
To be completed by Physician:
Student’s Name: Date of birth: School: Grade:
Asthma Severity: Intermittent Mild persistent Moderate persistent Severe persistent
Asthma symptoms are triggered by: Exercise Illness Pollen Smoke Air Pollution Animals Cold Air Molds
Foods: _____ __________________ _____________________ __ Other: __________________________ ______________
G
R
E
E
N
Z
O
N
E
SpO
2
____________________
Asthma Symptoms
• No Cough, wheeze or shortness of breath
• Able to do all normal activities including
exercise and play
• No need for quick relief medications for
symptoms
TREATMENT CHECK BELOW:
Use inhaler before exercise/activity then
participate normally.
______Puffs every ______
Other Medication:
______________________________
Y
E
L
L
O
W
Z
O
N
E
SpO
2 ____________________
Asthma Symptoms
• Coughing, wheezing, shortness of breath,
or chest tightness
• Using quick relief medication more than
usual
• Can do some but not all of usual activities
• Asthma night time symptoms
TREATMENT CHECK BELOW:
Inhaler ______Puffs every _____
 Nebulizer
 Other Medication:
R
E
D
Z
O
N
E
CALL 911 for SpO
2
of ___________
FOR ANY OF THESE ASTHMA SYMPTOMS!
Medication unavailable or not working
Chest/neck pulling in
Difficulty walking or talking
Getting worse not better
Breathing hard and fast
Lips or fingernails blue
Hunched over to breathe
TREATMENT CHECK BELOW:
Inhaler ______Puffs every ________
 Other Medication:
___________________________________
*ALERT EMERGENCY CONTACTS
MEDICATION/DOSAGE SELF-CARRY/SELF-ADMINISTER
Name of Medication
Dosage
Frequency
Name of Medication
Dosage
Frequency
PHYSICIAN SIGNATURE PHYSICIAN PRINTED NAME OFFICE PHONE DATE
Student may SELF-CARRY Inhaler YES NO
Student may SELF-ADMINISTER Inhaler YES NO
Physician initial: __________ The above student has demonstrated the
proper use of his/her rescue inhaler. I have instructed the student in the
correct and responsible use and confirm that the student is capable of
carrying and administering the prescribed rescue inhaler.
CALL
911
Physical Education/Recess Plan (check all that apply)
Attempt participation normally. If signs/symptoms occur stop activity and send to nurse. Not to participate in extensive running /jumping, but may walk or do other non-exertive activity.
Not to participate in physical activity at specials or recess during periods of exacerbation. Other: ______________________________________________________________________
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Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 101d
SELF-CARRY AND SELF-ADMINISTER ASTHMA RESCUE INHALER AGREEMENT
2021-2022 SCHOOL YEAR
To be completed by the Parent and Student:
Student name: _____________________________________________________ Date of Birth: _______________________
Where will student carry inhaler (required):
Additional inhaler will be provided to the school and stored with prescribed medication at specified school location:
(required):
STUDENT
I agree to carry my rescue inhaler with me as listed above and if an emergency arises and I am unable to get to the
nurse/school personnel I will use the rescue inhaler and then immediately inform a nurse/school personnel to
document the usage.
I agree to use my rescue inhaler in a responsible manner, in accordance with the physician’s orders. I understand my
asthma triggers, symptoms, and treatment plan reviewed by my physician and parent(s)/guardian(s) and understand to
use my rescue inhaler when an emergency arises and I am unable to get to the nurse/school personnel in time.
I will notify school personnel if I am having more difficulty than usual with my asthma.
I agree to never share my rescue inhaler with another person as this is dangerous and if I do this may result in
disciplinary action.
Student Signature: ______________________________________________ Date: __________________________
PARENT/GUARDIAN
I agree to see that my child carries his/her rescue inhaler as prescribed, and that it is properly labeled and is not
expired.
I understand that I will provide the school with an inhaler to store at school along with any prescribed medication
from the physician treatment plan.
I have reviewed with my child the asthma triggers, symptoms and treatment plan including the usage of the self-carry
rescue inhaler when an emergency arises.
I agree to regularly review with my child the proper use of his/her rescue inhaler when at school.
I agree to regularly review the status of my child’s asthma with the physician and to notify the physician when my
child is having more difficulty than usual.
I understand if my child shares medication with other students it may result in disciplinary actions.
My child has demonstrated to his/her physician and the school, nurse, if available, the skill level necessary to self-
administer the prescription medication, including the use of any device required to administer the medication.
The self-administration is done in compliance with the prescription or written authorization for my child to self-
administer the medicine while on school property or at a school-related event or activity.
I understand that such self-administration must be done in compliance with the prescription or written instructions of
my child’s physician. Additionally, I have provided a written and signed statement from my child’s physician that
states:
1. The student has asthma and is capable of self-administering the prescription medicine;
2. The name and purpose of the medicine; the prescribed dosage of the medicine; the times or
circumstances which the medicine may be administered; and the duration for which the medicine is
prescribed.
This is in effect for the current school year only unless revoked by the physician or the student, parent(s)/guardian(s)
fails to meet all the above safety contingencies.
Parent Signature: ________________________________________________ Date: ___________________________
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INDIVIDUALIZED HEALTHCARE PLAN FOR STUDENTS WITH ASTHMA 2021-2022

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Completed 28 June 2021

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