Colorado Department of Education Revised April 2015
COLORADOSCHOOLASTHMACAREPLAN
PARENT/GUARDIAN complete and sign the top portion of form.
StudentName: Birthdate:
Parent/Guardian: WorkPhone:
CellPhone: HomePhone:
OtherContact: Phone:
Grade: Teacher:
Triggers: Weather(coldair,wind) Illness Exercise Smoke Dust Pollen Other:____________________________________
Lifethreateningallergy:Specify__________________________________________________________
Ifthereisnoquickreliefinhaleratschoolandthestudentisexperiencingasthmasymptoms:
Callparents/guardianstopickupstudentand/orbringinhaler/medicationstoschool
Informthemthatiftheycannotgettoschool,911maybecalled
Igivepermissionforschoolpersonneltosharethisinformation,followthisplan,administermedicationandcareformychildand,ifnecessary,
contactourphysician.Iassumefullresponsibilityforprovidingtheschoolwithprescribedmedicationanddelivery/monitoringdevices.I
approvethisAsthmaCarePlanformychild.
_________________________________
_______________________________________________________________ 504PLANORIEP
PARENTSIGNATUREDATESCHOOLNURSESIGNATUREDATE
HEALTH CARE PROVIDER to complete all items, SIGN and DATE completed form.
GREENZONE:Studentparticipationinactivityandneedforpretreatment. Nocurrentsymptoms.
Pretreatmentforstrenuousactivity: NotRequired
Pretreatmentforstrenuousactivity:
RoutinelyOR UponrequestExplain:(weather,viral,seasonal,other)________________________
Give2puffsofquickreliefmed(CheckOne): Albuterol Other:_________________________________1015minutesbeforeactivity.

Repeatin4hoursifneededforadditionalorongoingphysicalactivity.
Ifstudentcurrentlyexperiencingsymptoms,follow yellowzone.
YELLOWZONE:SICKUNCONTROLLEDASTHMA
IFYOUSEETHIS: DOTHIS:
Troublebreathing
Wheezing
Frequentcough
Complainsofchesttightness
Notabletodoactivitiesbutstilltalkingin
completesentences
Peakflowbetween_____and______
Other:__________________________
1. Stopphysicalactivity
2. GIVEQUICKRELIEFMED:(CheckOne)
Albuterol Other:________________________

2puffs Other:___________________________________________
3. Callparents/guardiansandschoolnurse.
4. Staywithstudentandmaintainsittingposition.
5. Studentmaygobacktonormalactivitiesoncefeelingbetter.
Ifsymptomsdonotimprovein1015minutesorworsenaftergivingquickreliefmedicine,
followREDZONEplan.
REDZONE:EMERGENCYSITUATIONSEVEREASTHMASYMPTOMS
IFYOUSEETHIS: DOTHISIMMEDIATELY:
Coughsconstantly
Strugglestobreathe
Troubletalking(onlyspeaks35words)
Skinofchestand/orneckpullinwith
breathing
Lipsorfingernailsaregrayorblue
Levelofconsciousness
Peakflow<_____________________
1. GIVEQUICKRELIEFMED:(CheckOne): Albuterol Other:_______________________

2puffs Other:___________________________________________

Refertoanaphylaxisplanifstudenthaslifethreateningallergy.
2. Call911andinformEMSthereasonforthecall.
3. Callparents/guardiansandschoolnurse.
4. Encouragestudenttotakeslowdeepbreaths.
5. Ifsymptomscontinue,repeatquickreliefmed: Albuterol Other:_______________
2puffs Other:__________________________
6. Staywithstudentandremaincalm.
7. Ifin20minutesfromfirstdose,EMShasnotarrivedandsymptomsremain,repeatquick
reliefmedicine(upto4morepuffs). 
8. Schoolpersonnelshouldnotdrivestudenttohospital.
INSTRUCTIONSforQUICKRELIEFINHALERUSE:CHECKAPPROPRIATEBOX(ES)
Studentunderstandstheproperuseofhis/herasthmamedications,andinmyopinion,cancarryandusehis/herinhaleratschoolindependentlywith
approvalfromschoolnurse.
Studentistonotifyhis/herdesignatedschoolhealthofficialsafterusinginhaler.
Studentneedssupervisionorassistancetousehis/herinhalerandinhalerwillbekept(specifylocation)___________________________________________.
_________________________________________________________________________________________________________________
HEALTHCAREPROVIDERSIGNATUREPRINTPROVIDER’SNAMEPHONE/FAXDATE
Copiesofplanprovidedto:Teacher(s)___PhysEd/Coach___Principal____MainOffice___BusDriver___Other___________
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