Fillable Photoofchild PARENT/GUARDIAN complete and sign the top portion (School District 49, Colorado)

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Photoofchild PARENT/GUARDIAN complete and sign the top portion (School District 49, Colorado)

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Colorado Department of Education Revised April 2015

COLORADOSCHOOLASTHMACAREPLAN 

PARENT/GUARDIAN complete and sign the top portion of form.

StudentName: Birthdate:

Parent/Guardian: WorkPhone:

CellPhone: HomePhone:

OtherContact: Phone:

Grade: Teacher:

Triggers: Weather(coldair,wind) Illness Exercise Smoke Dust Pollen Other:____________________________________

Lifethreateningallergy:Specify__________________________________________________________

Ifthereisnoquickreliefinhaleratschoolandthestudentisexperiencingasthmasymptoms:

 Callparents/guardianstopickupstudentand/orbringinhaler/medicationstoschool

 Informthemthatiftheycannotgettoschool,911maybecalled

Igivepermissionforschoolpersonneltosharethisinformation,followthisplan,administermedicationandcareformychildand,ifnecessary,

contactourphysician.Iassumefullresponsibilityforprovidingtheschoolwithprescribedmedicationanddelivery/monitoringdevices.I

approvethisAsthmaCarePlanformychild.



_________________________________

_______________________________________________________________ 504PLANORIEP

PARENTSIGNATUREDATESCHOOLNURSESIGNATUREDATE

HEALTH CARE PROVIDER to complete all items, SIGN and DATE completed form.

GREENZONE:Studentparticipationinactivityandneedforpretreatment. Nocurrentsymptoms.

Pretreatmentforstrenuousactivity: NotRequired

Pretreatmentforstrenuousactivity:

RoutinelyOR UponrequestExplain:(weather,viral,seasonal,other)________________________

Give2puffsofquickreliefmed(CheckOne): Albuterol Other:_________________________________10‐15minutesbeforeactivity.



Repeatin4hoursifneededforadditionalorongoingphysicalactivity.

Ifstudentcurrentlyexperiencingsymptoms,follow yellowzone.



YELLOWZONE:SICK–UNCONTROLLEDASTHMA

IFYOUSEETHIS: DOTHIS:

 Troublebreathing

 Wheezing

 Frequentcough

 Complainsofchesttightness

 Notabletodoactivitiesbutstilltalkingin

completesentences

 Peakflowbetween_____and______

 Other:__________________________

1. Stopphysicalactivity

2. GIVEQUICKRELIEFMED:(CheckOne)

Albuterol Other:________________________



2puffs Other:___________________________________________

3. Callparents/guardiansandschoolnurse.

4. Staywithstudentandmaintainsittingposition.

5. Studentmaygobacktonormalactivitiesoncefeelingbetter.

Ifsymptomsdonotimprovein10‐15minutesorworsenaftergivingquickreliefmedicine,

followREDZONEplan.

REDZONE:EMERGENCYSITUATION–SEVEREASTHMASYMPTOMS

IFYOUSEETHIS: DOTHISIMMEDIATELY:

 Coughsconstantly

 Strugglestobreathe

 Troubletalking(onlyspeaks3‐5words)

 Skinofchestand/orneckpullinwith

breathing

 Lipsorfingernailsaregrayorblue

 Levelofconsciousness

 Peakflow<_____________________

1. GIVEQUICKRELIEFMED:(CheckOne): Albuterol Other:_______________________



2puffs Other:___________________________________________



Refertoanaphylaxisplanifstudenthaslifethreateningallergy.

2. Call911andinformEMSthereasonforthecall.

3. Callparents/guardiansandschoolnurse.

4. Encouragestudenttotakeslowdeepbreaths.

5. Ifsymptomscontinue,repeatquickreliefmed: Albuterol Other:_______________

2puffs Other:__________________________

6. Staywithstudentandremaincalm.

7. Ifin20minutesfromfirstdose,EMShasnotarrivedandsymptomsremain,repeatquick

reliefmedicine(upto4morepuffs). 

8. Schoolpersonnelshouldnotdrivestudenttohospital.

INSTRUCTIONSforQUICKRELIEFINHALERUSE:CHECKAPPROPRIATEBOX(ES)

Studentunderstandstheproperuseofhis/herasthmamedications,andinmyopinion,cancarryandusehis/herinhaleratschoolindependentlywith

approvalfromschoolnurse.

Studentistonotifyhis/herdesignatedschoolhealthofficialsafterusinginhaler.

Studentneedssupervisionorassistancetousehis/herinhalerandinhalerwillbekept(specifylocation)___________________________________________.



_________________________________________________________________________________________________________________

HEALTHCAREPROVIDERSIGNATUREPRINTPROVIDER’SNAMEPHONE/FAXDATE

Copiesofplanprovidedto:Teacher(s)___PhysEd/Coach___Principal____MainOffice___BusDriver___Other___________

Photoofchild

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Completed 14 June 2021

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