Parent/Guardian / PH # / Teachers
Asthma Triggers
To be completed by Healthcare Provider: (Please complete the following 3 sections/sign.)
You will see this: / The following medication(s) are taken ___at home ___ at school to manage/control asthma:■ / Breathing is good. / Medication: / How much: / When:
■ / No cough or wheeze.
■ / Can work & play easily.
■ / Sleeping all night.
If any symptom is present: / Step 1: / 5 2 puffs 5 4 puffs rescue inhaler every 20 minutes for up to 1 hour.
■ / Coughing. / 5 1 Nebulizer treatment.
■ / Wheezing. / Step 2: / Call school nurse, if symptoms do not improve
■ / Shortness of breath. / Call parent, if nurse is not on campus.
■ / Tightness in chest. / Step 3: / Call doctor, if: / ■ / Symptoms worsen.
■ / Can’t easily play or exercise. / ■ / Albuterol inhaler needed more often than every 4 hours.
■ / Can do some, but not all usual activities. / ■ / Albuterol inhaler needed every 4 hours for more than 1 day.
If any symptom is present: / Step 1: / Use NOW! 5 4 puffs 5 6 puffs rescue inhaler.
■ / Very short of breath. / 5 1 Nebulizer treatment.
■ / Breathing is very difficult or very fast. / Step 2: / Call 9-1-1. Student must go to the Emergency Room immediately.
■ / Using neck or stomach muscles to breathe.
■ / Nostrils are flaring/opening wide to breathe.
Signs of extreme danger:
■ / Trouble walking or talking.
■ / Lips or fingernails are blue.
I recommend the above-described medication be administered by trained school staff.
This student demonstrates competency and is capable of self-administering the medication(s) as listed above.
Additional comments:
Healthcare Provider – Print Name / Signature / Phone number / Date
To be completed by parent/legal guardian:
Yes, I give permission for trained staff to administer/assist in administering the medication(s) as listed above to my child.
Yes, I give permission for my child to self-carry and self-administer the medication(s) as listed above at school/school sponsored events.
Parent/Legal Guardian Signature / Best # to call you / Best # to text you / Date
To be completed by school nurse: / Staff trained in following asthma EAP and medication administration.
Student demonstrated competency in self-administering medication.
School Nurse Signature Contact # Date
Original to school nurse (IHR); copies to appropriate staff. Rev: 10/2016