Jefferson County Public Schools Health Services Primary Care Provider Authorization (PCP): Asthma/Allergy (Side One) 2012-2013 School Year Student Name: ______________________________ Date of Birth: _____________ School: _____________________________ Does this child have ALLERGIC REACTIONS? __ YES __ NO Does this child have ASTHMA? ____ YES ____ NO hat things cause this student’s allergic reaction? __ Medications _____________________ What things may bring on this child’s asthma? __ Stinging Insects __________________ __ Pollens __ Dust __ Animals __ Exercise __ Foods __ Other ___________________________ __ Illness __ Other_________________________________ FOOD ALLERGY? __ YES __ NO Asthma SYMPTOMS may include: Coughing, Shortness of Breath, Please list any food allergies: _________________________________________ and Wheezing. Please list any other symptoms specific for this child: Any food not to be served to student: __________________________________ _________________________________________________ Is student Lactose Intolerant? __ YES __ NO *Please refer to Emergency Plan of Action on Side Two for symptoms Nutritional info available at indicating an emergency asthma situation. you may call 485- 3186 for more information. Asthma Medications AT SCHOOL: Order will be for current school year unless otherwise indicated. SYMPTOMS of the allergic reaction for this child: __Itching/Swelling of Lips, Mouth, Tongue or Throat __ Albuterol (Ventolin, Proventil, ProAir, etc) __Hives/Rash __Nausea/Vomiting/Stomach Cramps __ 2 puffs every 4-6 hours as needed __Shortness of Breath __Wheezing __Coughing __ 2 puffs ___ minutes prior to exercise __Dizziness __Unconsciousness __ Other __________________________ __ Other____________________________________ Medications AT SCHOOL: __ Other medication ________________________________ Order will be for current school year unless otherwise indicated. Instructions ___________________________________ __ EpiPen Jr. __ EpiPen __ Twinject *If student needs inhaler more than twice a week, please notify parent. ___ Give Epipen/Twinject at onset of allergic reaction and/or exposure to allergy trigger. Is this student trained and capable of carrying their own inhaler and ___ Other instructions__________________________________________ using it on their own? ___ YES ___ NO ***IF 2nd DOSE OF TWINJECT OR 2nd EPIPEN NEEDED, give: If student not carrying inhaler, it is to be kept: ____ Minutes after 1st Dose __ In front office or student classroom __ Other _________________________________________ Other medications: _____________________________________________ May student carry own EpiPen/Twinject and use on their own? __ YES __ NO If student not carrying EpiPen/Twinject, it is to be kept: __ In front office or student classroom __Other ______________
Initials/Date Reviewed by Health Services ___________ Entered by Health Services ___________ School received/sent to Health Services ___________
Jefferson County Public Schools Health Services Primary Care Provider Authorization (PCP): Asthma/Allergy (Side Two) 2012-2013 School Year Student Name: ______________________________ Date of Birth: _____________ School: _____________________________ EMERGENCY PLAN OF ACTION 1. Follow orders on page 1 for Asthma and/or Allergy treatments and medications. 2. If student is hunched over and/or having dif iculty breathing, walking or talking, blue fingernails or lips, peak flow meter reading in red zone and/or medications not helping, cal EMS 3. Notify school personnel trained in CPR/first aid to respond and initiate CPR if needed prior to EMS arrival. 4. Notify parent/guardian. 5. If EMS is called, the student must be transported via EMS to emergency facility, or parent/guardian must sign release with EMS and then parent/guardian assumes responsibility for student. The student may not return to school that day. When student is transported via EMS, JCPS staf must ride with student unless parent and/or emergency contact accompanies them. 6. If student requires medical treatment while on the bus, the bus driver wil contact EMS.
7. Other: ____________________________________________________________________________________________________________________________________________________ FORM MUST BE SIGNED BY HEALTH CARE PROVIDER AND PARENT/GUARDIAN
_______________________________ _______________________________ _________________________________ Printed Name of MD, APRN, or PA
Parent/guardian hereby acknowledges that if this medication is not self-administered, it will most likely be administered by trained, unlicensed JCPS personnel. I acknowledge and agree when I authorize my child to attend a school sponsored field trip, this medication and/or health service may also be administered by a licensed volunteer. By signing this form, the parent/guardian shall acknowledge that the Jefferson County Board of Education and its employees shall incur no liability as a result of any injury sustained by the student from the self-administration of his/her medications to treat asthma or anaphylaxis and the parent/guardian shall indemnify and hold harmless the school and its employees against any claims relating to self-administration of school medication. This form shall not relieve the liability of the school or its employees for their own negligence. I hereby give permission for the health care provider completing and signing this form to verify this information with JCPS and consult with JCPS staff regarding this information. **Parent/Guardian signature required only for INITIAL 2012-2013 PCP form. Parent/Guardian signature not required for updated 2012-2013 PCP form.
PLEASE RETURN THIS COMPLETED FORM TO: Jefferson County Public Schools - Health Services Department Lam Building, 4309 Bishop Lane, Louisville, KY 40218 Telephone No. (502) 485-3387 Fax: (502) 485-3670 DRAFT 5/22/12