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Individualized Health Care Plan Student Name: School Year: Headache Individualized Healthcare Plan SECTION I Student: WT: HT: Grade: D.O.B Any Known Allergies School: District: Bus (check one) ☐YES ☐NO Bus #AM Bus #PM School Nurse: Phone # Cell # Medication taken at home: (please list)
Contacts
Mother Home # Work # Cell # Father Home # Work # Cell # Guardian/Custodian Home # Work # Cell # Home Address City # Zip Emergency Contact (Relationship) Home # Work # Physician Phone # Fax# Physician Address City Zip
Date Special Notes
Individualized Health Care Plan Student Name: School Year: Headache Individualized Healthcare Plan SECTION II: EMERGENCY ACTION PLAN IF YOU SEE THIS… DO THIS… Light sensitivity Notify School Nurse Nausea / vomiting Notify School Nurse Blurred vision Notify School Nurse Dizziness Notify School Nurse Severe pain Notify School Nurse Other related information: Is a PRESCRIBER/PARENT AUTHORIZATION (PPA) on file for this student? □ No □ Yes
- PRESCRIBER/PARENT AUTHORIZATION (PPA) is required for all medication given at school Notes /Special Instruction__________________________________________________________________________________________________
Individualized Health Care Plan Student Name: School Year: Written Notes/Addendum to Plan of Care I understand and agree with this Individualized Healthcare Plan. I give permission for my child to be transported to the hospital indicated on this form, in the event of an emergency. I give permission for the release of my child’s medical information, in the event of an emergency. _ Signature of Parent or Guardian Date Signature of School Nurse Date DATE PARENT/ GUARDIAN INTIALS (if needed)
Individualized Health Care Plan Student Name: School Year: Communication of the Individualized Health Care Plan SECTION IV: ☐ Check this Box if Read Receipt is used to communicate Individualized Health Care Plan to staff.
- Nurse to attach Read Receipt document to this packet. ☐ Check this box if staff receives and signs below for Individualized Health Care Plan. I have read and understand this student’s Individualized Healthcare Plan, and have printed a copy to be maintained in my confidential folder/binder of instructions for substitute teachers. I have been given the opportunity to ask questions. I understand my role in addressing this students medical needs. I am aware the school nurse is available to help clarify any future concerns. Employee Name Employee Signature Position Held Date
