asthma action plan / medication authorization form

Asthma Action Plan/Medication Authorization Form
For all children with asthma Mecklenburg County Health Dept.
Student Name ______________________________
CMS Student ID# ____________________________________
School/Year ______________________________
Grade/Teacher
______________________________________
Parent/Guardian ______________________ Contact Number (H) ______________Cell______________ Work___________
Physician’s Name_____________________ Physician Phone Number _____________________ Fax ____________________

1. NO SMOKING in your home or car, even if your child is not with you.
2. Always use a spacer with inhalers (MDIs).
3. Shake inhaler before every spray (puff).
4. Remove, control and stay away from known triggers in your child’s environment.
5. Clean plastic part of inhaler weekly using package directions.
6. Prime inhaler after opening and before use if not used in more than two weeks. Proair-three puffs, all others four puffs.
Child’s triggers are: (circle or check all that apply to your child)
 Respiratory infections or flu
allergies_________________________________
GREEN ZONE – ALL CLEAR – GO!
USE CONTROLLER MEDICINES
ASTHMA IS WELL CONTROLLED
 No controller medicine needed at this time
You should have:
Medicine
Method How Much How often
__________________ _________ ________ ______times per day __________________ _________ ________ ______times per day No waking up at night because of asthma __________________ _________ ________ ________________ No problems with play because of asthma __________________ _________ _________ ________________
Peak flow number from _____ to _____ 15 minutes before exercise use __________ puffs (inhaled) _____________
ONE – CAUTION! – TAKE ACTION
TAKE QUICK RELIEF MEDICINE
ASTHMA GETTING WORSE
Continue to use green zone daily medicines and add:
You may have:
Medicine Method How much How often
Albuterol/Xopenex inhaled ____puffs OR ____vial Every ___hours prn Also take:
Chest Tightness ___________________ _____________ ______________ ____________ Coughing at night If yellow zone symptoms continue for 24 hours or child needs extra rescue Peak flow number from _____ to _____ medicine more than 2 times per week, call your child’s doctor.
RED ZONE – STOP! – GET HELP NOW!
TAKE QUICK RELIEF MEDICINE
THIS IS AN EMERGENCY!
You may have:
Quick relief medicine that is not helping Continue to use green zone medicines and do the following:
_____ puffs or 1 vial Albuterol/Xopenex inhaled every CALL DOCTOR NOW! If you cannot reach doctor, CALL 911
Chest and neck pulled in with each breath or go directly to the EMERGENCY ROOM
Or Peak flow less than ______________
DO NOT WAIT!
Physician Signature________________________________________________
Date________________________________
Parent/Guardian Signature_________________________________________
Date________________________________
School Health Nurse Signature ______________________________________
Date________________________________
Student self carries inhaler Y/N Inhaler in the Health Room Y/N Inhaler in classroom Y/N CI 45 3/09
AUTHORIZATION FOR SELF-MEDICATION BY CMS STUDENTS

Student's Name__________________________________________ Birthdate______________________
Medication___________________________________for ____________________________________

Eligibility: In accordance with CMS Policy JLCD, Administering Medications to Students, and its accompanying
regulation, JLCD-R, only students who meet the following descriptions may possess and self-administer medications:
(1) Students with special medical needs such as asthma and/or severe allergies or who are subject to anaphylactic
reactions and may require emergency medications (i.e., asthma inhaler or epinephrine auto-injector [“Epi-pen]); and (2)
Students who require frequent administrations of non-prescription medications or prescription medications that are not
controlled substances.
- - - - - - - - - - - - - - - - - - - - - - - - - - -
Healthcare Provider: The student named above has (1) asthma or an allergy that could result in an anaphylactic
reaction and may require emergency medications; or (2) a condition that requires frequent administration of a
prescription or non-prescription medication. The medication is not a controlled substance. This student is capable of,
has been instructed on the procedures for and has demonstrated the skill to self-administer this medication as directed
on page 1 of this form. Please allow him/her to self-administer the medication during school hours and as otherwise
indicated on page 1 of this form.
This
will not require adult supervision while taking this medication. Physician signature/date____________________________________________

Parent/Guardian: I give consent to the Charlotte-Mecklenburg Schools to allow my child to self-administer this
medication at school. I understand that my child and I assume responsibility for the proper use and safekeeping of this
medication. If the medication that is prescribed for my child is for the treatment of asthma or anaphylactic reactions, I
agree to provide a supplementary supply of the medication that will be kept by the school in a location to which my
child has immediate access. I absolve the Charlotte-Mecklenburg Board of Education and their agents and employees
from any and all liability whatsoever that may result from my child possessing or taking this medication at school. I
further consent for the information about my child included on pages 1 and 2 of this form to be shared with appropriate
school staff as necessary for the safety of my child.
Parent signature/date ______________________________________________

Student: I am capable of taking this medication as recommended and accept this responsibility. I will keep it secure at
all times and will not share it with others. I understand that I will be subject to discipline under the Student Code of
Conduct if I abuse the privilege of being allowed to self-medicate while at school or school sponsored activities. Unless
the medication is prescribed for the treatment of asthma or anaphylactic reactions, I understand that I will lose the
privilege of self-administering my medication if I do not follow these rules.
Student signature/date _______________________________________________

School Nurse: I have reviewed this request and acknowledge that this student has demonstrated the skill level to self-
administer this medication. I have informed this student that he or she must tell an appropriate staff member whenever
he or she has used the medication at school.
Nurse signature/date __________________________________________________

Source: http://butlerhealth.cmswiki.wikispaces.net/file/view/Asthma%20Action%20Plan%2003-09%5B1%5D.pdf/441907236/Asthma%20Action%20Plan%2003-09%5B1%5D.pdf