Order for Vagal Nerve Stimulator Device in School
Student’s Name:______DOB______Teacher ______Grade______
Parent/Guardian Name______phone______phone______
Name______phone______phone______
Emergency contact ______Phone______
(relationship)
Please have the student’s Doctor complete the following information:
1. Observe seizure activity and time the seizure.
2. If seizure is longer than _____minutes in duration, swipe the magnet from midline of the chest in a right downward motion.
3. Wait _____ seconds and repeat swipe.
4. Repeat ______times waiting ______seconds in between and observe student for further seizure activity.
5. If student continues to have a seizure longer than ______minutes, Call 911
6. Call Parent/Guardian
7. Document on Seizure Flow Sheet
8. Activity restrictions if any:______
9. Other: ______
Physician Name ______Phone:______
Address: ______
Physician Signature______Date______
Duration of order: School Year ______
I have reviewed this order and give my permission for the School Health Nurse to train school personnel to follow this order. I authorized the release and exchange of medical and educational information between my child’s physician and school staff that is necessary in carrying out this service to my child.
Parent/Guardian Signature______Date______
I have provided training and instruction regarding this order to
Print name______
I have read the above Vagal Nerve Stimulator Magnet Swipe procedure and understand the directions.
Sign name______
School Nurse Signature______Date______
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