ࡱ>  Zbjbj$$ .F|F|$""||8Yv<LLLLE"#lununununununu$xzNui$@Ei$i$u||LLvY(Y(Y(i$|8LLluY(i$luY(Y(LUD XL:%V&Xu)v0YvVj{%{L X{ X8i$i$Y(i$i$i$i$i$uu'i$i$i$Yvi$i$i$i${i$i$i$i$i$i$i$i$i$" B:  FORMTEXT       School Phone # FORMTEXT      School Fax # FORMTEXT       FORMTEXT       Seizure Action Plan This student is being treated for a seizure disorder. The information below may assist if a seizure occurs during school hours or at school activities. Student Name: FORMTEXT      Date of Birth: FORMTEXT      School: FORMTEXT      Parent/Guardian: FORMTEXT      Home Phone: FORMTEXT       Cellular: FORMTEXT      Primary Physician: FORMTEXT      Phone: FORMTEXT       FAX: FORMTEXT      Neurologist: FORMTEXT      Phone: FORMTEXT      FAX: FORMTEXT      Physician completes form from this point forward.Significant Medical History: FORMTEXT       Seizure InformationSeizure TypeLengthFrequencyDescriptionLast Seizure Date FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Seizure triggers or warning signs:  FORMTEXT      Student s response after seizure: FORMTEXT       Seizure Response  BASICAdditional Individual Student Information:Stay calm and record start of seizureParent requests notification after each seizure  FORMCHECKBOX  Yes  FORMCHECKBOX  NoKeep child safe but Do NOT restrainDoes student need to leave the classroom after a seizure?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do not put anything in mouthIf YES, describe process for returning student to classroom: FORMTEXT      Stay with child until fully conscious FORMTEXT      Document ending time and description of seizureTonic-clonic seizure additional response: " Protect child s head " Turn child on side " Keep airway open " Monitor breathingIn case of incontinence, parent should provide extra clothing for school so student may return to class as allowed by process above.  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSeizure Response EMERGENCYA Seizure is Generally Considered an Emergency When: FORMCHECKBOX  Call 911 for paramedicsConvulsive (tonic-clonic) seizure lasts longer than 5 minutes FORMCHECKBOX  Contact school nurse Student has repeated seizures without regaining consciousness FORMCHECKBOX  Administer emergency medications if indicated belowStudent is injured, has diabetes, or is pregnant FORMCHECKBOX  Notify parents or emergency contact (as listed above)Student has a first-time seizure FORMCHECKBOX  Notify doctor listed aboveStudent has breathing difficulties FORMCHECKBOX  Other:Student has a seizure in water A seizure emergency for this student is additionally defined as: FORMTEXT &(  ( * , 6 8 < ⡒xfxQxx?xQx#jvhQ<hWOJQJU(jhQ<hWOJQJUmHnHu#jxhQ<hWOJQJUjhQ<hWOJQJUhQ<hWOJQJhW5>*CJOJQJaJhW5OJQJaJ)jhW5CJOJQJUmHnHu*jhWh5CJOJQJUhW5CJOJQJjhW5CJOJQJUjh}UmHnHu : ikd$$Ifl0  , t 6`F644 lapytQ<$F&`#$/IfgdQ<gdW: < K L M  , vvv$ !$Ifa$gd WWgd WWgd WgdWikd$$Ifl0  , t 6`F644 lapytQ< < > R T V ` b 7 J L M 垓{ld\dUJ:hmC<h65CJOJQJaJh2:h*CJaJ hR+hR+hnOJQJhR+OJQJhWhWCJOJQJaJhWhW5CJOJQJaJhWOJQJh Wh WCJaJhhWCJOJQJaJhW5CJOJQJaJ)jhW5OJQJUaJmHnHu*jthWh5OJQJUaJhW5OJQJaJjhW5OJQJUaJ   , . 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FORMCHECKBOX  Yes  FORMCHECKBOX  No, If YES, describe magnet use:  FORMTEXT      Call 911 if still seizing after  FORMTEXT      VNS swipes. Wait  FORMTEXT      minutes between swipes. Give  FORMTEXT      swipes before any emergency medication. Special Considerations and Precautions (regarding school activities, sports, trips, helmet use, or bus riding after seizure, etc.)Describe any special considerations or precautions: FORMTEXT       FORMTEXT       Physician Name: FORMTEXT      Physician Signature:Date: FORMTEXT      I give permission for school staff to contact the physician for consultation and exchange of information as needed.Signature of Parent or Guardian:Date: FORMTEXT      Phone Number: FORMTEXT       This form must be renewed annually or with any change in treatment or medication. The Medication Administration Form must be completed in addition to the Seizure Action Plan if medication is required at school or school activities.     * Medication Administration Form Required San Bernardino County School Nurse & Physician Collaborative Seizure Action Plan, 4.11.14 The EpiPen can be injected through clothing. The individual may feel heart pounding. 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