аЯрЁБс > ўџ F H ўџџџ E џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС Р јП оU bjbjOO $u -a -a x џџ џџ џџ З n n Ш Ш T T T $ џџџџ x x x x \ д d x 9 8 | Д Д Д ю 0 Ё0 T ѕ0 , i8 k8 k8 k8 k8 k8 k8 $ Ј: В Z= H 8 E T ї3 +, т 0 ї3 ї3 8 Ш Ш Д ю = д8 %7 %7 %7 ї3 " Ш Д : T ю i8 %7 ї3 i8 %7 %7 : х7 , V ў %8 ю џџџџ АзИ ыЮ џџџџ 4 О 8 U8 ъ8 0 9 8 Ђ= з4 D Ђ= %8 Ђ= T %8 0 !1 Г1 h %7 2 T o2 !1 !1 !1 8 8 7 !1 !1 !1 9 ї3 ї3 ї3 ї3 џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ џџџџ Ђ= !1 !1 !1 !1 !1 !1 !1 !1 !1 n : Asthma Action Plan Name: Date:Birth Date: Provider Phone #: Fax #:Patient Goal: Parent/Guardian Phone #:Important! Things that make your asthma worse (Triggers): Ё% d u s t Ё% p e t s Ё% m o l d Ё% s m o k e Ё% p o l l e n Ё% c o l d s / v i r u s e s Ё% o t h e r _ _ _ _ _ _ _ _ _ _ _ _ _ _ S e v e r i t y : Ё% S e v e r e P e r s i s t e n t Ё% M o d e r a t e P e r s i s t e n t Ё% M i l d P e r s i s t e n t Ё% M i l d I n t e r m i t t e n t P E R S O N A L B E S T P E A K F L O W : _ _ _ _ _ _ _ _ _ _ P r o v i d e r S i g n a t u r e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________Date___________________________________ Parent/Guardian to complete this section: I, _____________________________________________give permission to the school nurse and/or the school-based health clinic to exchange information and otherwise assist in the asthma management of my child including direct communication with my childs primary care provider. __________________________________________________Date:____________________ (parent/guardian signature) Marlborough Elementary School 25 School Drive; Marlborough CT 06447 (860) 295-6225 FAX (860) 295-6223 AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINE BY SCHOOL PERSONNEL Connecticut State Law and Regulations 10-212(a) require a written medication order of an authorized prescriber, (physician, dentist, advanced practice registered nurse or physicians assistant) and parent/guardian written authorization, for the nurse, or in the absence of the nurse, a designated principal or teacher to administer medication. Medications must be in the original properly labeled container and dispensed by a physician/pharmacist. Prescribers Authorization Name of Student: ______________________________________________ Date of Birth: _______________ Address: _______________________________________________________________________________ Condition for which drug is being administered: ________________________________________________ Drug Name: _____________________________ Dose: _______________________ Route: ____________ Time of Administration: _________________________________ If PRN, frequency: ___________________ Relevant side effects: FORMCHECKBOX None expected FORMCHECKBOX Specify: __________________________________________ ALLERGIES: FORMCHECKBOX NO FORMCHECKBOX YES (specify): _____________________________________________________ Medication shall be administered from: __________________________to __________________________ Month / Day / Year Month / Day / Year Prescribers Name/Title: ______________________________________ (Type or print) Telephone: ____________________ Fax: _______________________ Address:__________________________________________________ __________________________________________________ Prescribers Signature: ________________________ Date: _________ Use for Prescribers Stamp PARENT/GUARDIAN AUTHORIZATION I hereby request that the above ordered medication be administered by school personnel. I understand that I must supply the school with no more than a 45 day supply of medication. I understand that this medication will be destroyed if not picked up within one week following termination of the order or the last day of school, whichever comes first. Parent/Guardian Signature: _________________________________________ Date: _____________________ Parents Home Phone #: ___________________________________Work #: ____________________________ SELF ADMINISTRATION OF MEDICATION AUTHORIZATION/APPROVAL Self administration of medication may be authorized by the prescriber and parent/guardian and must be approved by the school nurse in accordance with Board policy. Prescribers authorization for self administration: FORMCHECKBOX Yes FORMCHECKBOX No __________________________________________ Signature Date Parent/Guardian authorization for self administration: FORMCHECKBOX Yes FORMCHECKBOX No _______________________________________ Signature Date School nurse approval for self administration: FORMCHECKBOX Yes FORMCHECKBOX No ___________________________________________ Signature Date GO Youre Doing Well! ( Use these medicines everyday: You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play Personalt Peak Flow: ________ MEDICINE HOW MUCH HOW OFTEN/WHEN Puffs Xs per day Tabs AM PM Nebulizer Puffs Xs per day Tabs AM PM Nebulizer OR Peak flow from _______ to _______ EMBED MSPhotoEd.3 CAUTION Slow Down! ( Continue with green zone medicine and add: You have any of these: First signs of a cold Exposure to known trigger Cough Mild wheeze Tight Chest Coughing at night Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Ribs show Cant talk well MEDICINE HOW MUCH HOW OFTEN/WHEN Puffs Xs per day Tabs AM PM Nebulizer Puffs Xs per day Tabs AM PM Nebulizer You have any of these: First signs of a cold Exposure to known trigger Cough Mild wheeze Tight chest Coughing at night Coughing at night OR Peak flow from _______ to _______ EMBED MSPhotoEd.3 CALL YOUR HEALTH CARE PROVIDER: DANGER Get Help! ( Take these medicines and call your provider now. 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