1

Henry County Public Schools Health Services

Primary Care Provider Authorization: SEIZURE

Student Name: ______

Date of Birth: ______

School: ______

School Year: ______

Type of Seizure:

[ ] Grand Mal (Tonic-Clonic) [ ] Petit Mal (Absence) [ ] Other ______

Please list any medications student is presently taking for control of seizures:

Medication / Dose / Time / Route / Give At School / Given At Home

List any restrictions or storage requirements for meds being administered at school: ______

______

Please specify likely characteristics
/

Recommended intervention or additional comments

Aura

/ [ ]Yes [ ] No
Describe conditions or behaviors that usually precede the seizure:
Duration
Frequency / Specify seconds, minutes, etc…
How often do seizures occur?
Extremities /

Limp

/ Flexed / Extended / Jerking

R arm

/ [ ] / [ ] / [ ] / [ ]
L arm / [ ] / [ ] / [ ] / [ ]
R leg / [ ] / [ ] / [ ] / [ ]
L leg / [ ] / [ ] / [ ] / [ ]
Eyes /

Rolled back

/ [ ]Yes / [ ]No

Staring straight ahead

/ [ ]Yes / [ ]No

Twitching back and forth

/ [ ]Yes / [ ]No
Looking to right / [ ]Yes / [ ]No
Looking to left / [ ]Yes / [ ]No
Mouth / Drawn to right / [ ]Yes / [ ]No
Drawn to left / [ ]Yes / [ ]No
Bites tongue or cheek / [ ]Yes / [ ]No
Teeth Clenched / [ ]Yes / [ ]No
Breathing / Noisy breathing / [ ]Yes / [ ]No
Heavy breathing / [ ]Yes / [ ]No
Shallow breathing / [ ]Yes / [ ]No
Other / Change in skin color / [ ]Yes / [ ]No
Drooling / [ ]Yes / [ ]No
Incontinent of urine / [ ]Yes / [ ]No
Incontinent of stool / [ ]Yes / [ ]No
Vomiting / [ ]Yes / [ ]No

School procedure for a student having a seizure is:

  1. Ease student to the floor (unless harnessed securely in a wheelchair and breathing is not restricted)
  2. Remove hazards in the area, such as sharp or hard objects, to prevent injury
  3. Loosen tight clothing at the neck
  4. Turn student onto his/her side to allow saliva/vomit to drain and maintain an open airway
  5. Cushion the student’s head with something soft
  6. Monitor student while the seizure runs its course and speak to him/her in calming tones
  7. Following the seizure, allow the student to rest as needed in a quiet supervised area
  8. Following each occurrence, report activity to parent/guardian in writing and/or by telephone
  9. Other actions: ______

**Emergency Plan of Action and Bus Plan of Action**

Signals of a situation that would require emergency action:

  • Any seizure lasting longer than five (5) minutes, or
  • Continued, progressive respiratory distress, or
  • If another seizure starts right after the first without time for recovery

Emergency action:

  • Call EMS (9 - 911) and notify school nurse immediately
  • For absence of breathing and/or pulse, trained school staff should initiate CPR
  • Contact parent/guardian or emergency contact immediately

[ ] Administer rectal diastat (dose/instructions): ______

Does your child ride a school bus? [ ] No [ ] *Yes *Provide all bus numbers: ______

Does diastat need to be available on the school bus?[ ] No [ ]*Yes *Student must either keep diastat with them at all times, or parents must send in extra medication for the bus.

  • If student has a seizure, bus drivers will call 911 and follow school procedure as outlined above
  • Diastat will only be administered by a trained Medical Professional upon their arrival to the bus

Physician name and address: ______

Physician signature: ______Date: ______Telephone: ______Fax: ______

**Note to parent: Signing this form shall release Henry County Public Schools and staff from liability of any nature that might result from actions directly related to this plan of care. The parent also understands that he/she has the ultimate responsibility for providing the school with updated medical information that may affect this child’s plan of care and also for providing the school with an adequate supply of medication to enable the physician’s orders to be followed:

Printed name & number of parent/guardian: ______

Signature of parent/guardian: ______Date: ______

Please complete this form in its entirety and return to:

Henry County Public Schools Health Services

Melissa S. Jeffries, RN, BSN

326 South Main Street

New Castle, KY 40050

Telephone: (502) 845-8600Fax: (502) 845-8601

Revised April 30, 2012 MSJ