Virginia Asthma Action Plan School Division: Prince George County Public Schools_____________________________________Page 1 of 3 Date of Birth Effective Dates Health Care Provider Provider’s Phone # Fax # Last flu shot / / / Parent/Guardian Parent/Guardian Phone Parent/Guardian Email: Additional Emergency Contact Contact Phone Contact Email Asthma Severity: IntermittentorPersistent: Mild Moderate Severe Asthma Triggers (Things that make your asthma worse)
□ Colds □ Smoke (tobacco, incense) □ Pollen □ Dust □ Animals:_________________ □ Strong odors □ Mold/moisture □ Stress/Emotions
□Exercise □ Acid reflux □ Pests (rodents, cockroaches) □ Season (circle): Fall, Winter, Spring, Summer □ Other:______________________
Green Zone: Go! — Take these CONTROL (PREVENTION) Medicines EVERY Day Always rinse your mouth after using your inhaler and remember to use a spacer with
You have ALL of these: your MDI.
Dulera ______ Symbicort ______ Advair ______ , ____ puff (s) ____ times a day
Combination medications: inhaled corticosteroid with long-acting -agonist
Alvesco _____ Asmanex ____ Azmacort _____ Flovent ____ Pulmicort QVAR ____
Inhaled Corticosteroid or Inhaled corticosteroid/long-acting -agonist
____ puff (s) MDI ___ times a day Or ____ nebulizer treatment (s) ___ times a day Peak flow: _______ to _______
Singulair or __________________________, take ____ by mouth once daily at bedtime
Personal best peak flow:________ For asthma with exercise, ADD: Albuterol or ____________________, _____ puffs with Yellow Zone: Caution! — Continue CONTROL Medicines and ADD RESCUE Medicines
You have ANY of these:
Albuterol or __________________, ____ puffs with spacer every ____ hours as needed
Albuterol or _________________, one nebulizer treatment (s) every ____ hours as needed
Inhaled agonist Call your Healthcare Provider if you need rescue medicine for more than 24 hours or two times a week, or if your rescue medicine doesn’t work. Peak flow: _______ to ______ (60% - 80% of Personal Best) ROL & ROL & RES
You have ANY of these:
Albuterol or ______________, __ puffs with spacer every 15 minutes, for THREE treatments Inhaled -agonist
Albuterol or ____________, one nebulizer treatment every 15 minutes, for THREE Inhaled -agonist Call your doctor while administering the treatments. IF YOU CANNOT CONTACT YOUR DOCTOR: Call 911 or go directly to the Peak flow: < _______ Emergency Department NOW! REQUIRED SIGNATURES: SCHOOL MEDICATION CONSENT & HEALTH CARE PROVIDER ORDER
I give permission for school personnel to follow this plan, administer medication
CHECK ALL THAT APPLY:
and care for my child and contact my provider if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/
Student instructed in proper use of their asthma medications, and in my
monitoring devices. I approve this Asthma Management Plan for my child.
opinion, CAN CARRY AND SELF-ADMINISTER INHALER AT SCHOOL. PARENT/GUARDIAN _____________________________ Date ________ Student is to notify designated school health officials after using inhaler at school. SCHOOL NURSE/DESIGNEE ________________________ Date ________ Student needs supervision or assistance to use inhaler. OTHER ______________________________________ Date ________ ____Student should NOT carry inhaler while at school. CC: Principal Cafeteria Mgr Bus Driver/Transportation MD/NP/PA SIGNATURE: ____________________________ DATE_______
Coach/PE Office Staff School Staff
Blank copies of this form may be reproduced or downloaded from www.virginiaasthma.org
Virginia Asthma Action Plan approved by the Virginia Asthma Coalition (VAC) 4/11
Based on NAEPP Guidelines and modified with permission from the D.C. Asthma Action Plan via District of Columbia
Department of Health, DC Control Asthma Now, and District of Columbia Asthma Partnership
Asthma Health Care Action Plan and Medication Administration Authorization Page 2 of 3 Student’s Name:_________________________________________ DOB:__________________ School: _______________________
Medication Allergies:_____________________________________________________________ School Year: __________________
I, ____________________________________________, parent or legal guardian of above student, request that the principal’s
designee at ________________________________________ School administer the prescribed medication and provide care to my
child as indicated on the Asthma Health Care Action Plan dated ________________________________. I give the school nurse
and/or principal’s designee permission to contact the licensed prescriber if necessary. In signing this form, I am agreeing to hold the
school and its personnel free from any legal action that might arise from this arrangement.
I also understand that I am to abide by the school division regulations as stated below:
• It is my child’s responsibility to come to the clinic to take his/her medication.
• Parent or guardian must bring medication into school office or clinic. Medication cannot be transported on buses or by students.
• The first dose of a new medication should be given at home.
• Prescription medication must have a current prescription label that corresponds with the written authorization.
• Any changes in a medication require a new written authorization and corresponding change in the prescription label.
• Parent or guardian must provide medications/equipment required to administer medications or provide special medical care.
• Left over medication must be picked up at the end of the school year or it will be discarded.
• Students with a diagnosis of asthma may possess and self-administer inhaled asthma medications during the school day, at
school-sponsored activities, and while on the bus or other school property provided the following conditions are met: The student must have written consent from a parent or guardian and from a physician or nurse practitioner that identifies the
name, dosage and frequency of medication and circumstances which warrant such medication to be self-administered.
The physician must confirm that the student demonstrates ability to safely and effectively self administer medication; The parent must provide an individualized health care plan including emergency procedures for any life-threatening
The permission to possess and self-administer inhaled asthma medications shall be effective for one year, defined as 365
calendar days, and must be renewed annually.
The parent or guardian will be notified by a school official before any limitations or restrictions are imposed upon a student’s
possession and self-administration of inhaled asthma medications.
It is the student’s responsibility to notify a teacher or school health official after self administering medication.
I give permission to share information about my child’s asthma with the school nurse, teachers, principals, office staff, guidance,
bus driver/transportation and cafeteria manager as appropriate. I give the principal or his designee the authority to call the rescue squad or
take my child to a hospital emergency room in case of emergency.
Parent/Guardian Signature _______________________________________________________________________ Date _____________________________________ Parent/Guardian PRINTED Name ___________________________________________________________________________________________________________ PHONE: Home:_____________________________________ Work:______________________________________ Cell:______________________________________ Asthma Health Care Action Plan and Medication Administration Authorization Page 3 of 3
Student’s Name:_______________________________________________ School Use:
Health care plan information provided by __________________________________________ to the following staff:
Names of Persons and Date Names of Persons and Date
Staff members trained to administer medication and assist with this student’s care at school in the absence of the nurse:
Name of Person Location or Room Number Date Trained
Journal of Medical Microbiology (2006), 55, 127–131Detection of mixed infections with Mycobacteriumlentiflavum and Mycobacterium avium by moleculargenotyping methodsPhilip Suffys,1 Adalgiza da Silva Rocha,1 Adeilton Branda˜o,2Bart Vanderborght,3 Wouter Mijs,4 Geert Jannes,4 Fernanda C. Q. Mello,3Heloisa da Silveira Paro Pedro,5 Leila de Souza Fonseca,6Rosaˆngela Siqueira de Oliveira,7 Sylvia
National Office 175 Bloor Street East Suite 700, North Tower Toll Free: 1-866-922-6065 Fax: 416-922-7538 Text on the screen: Women and Wellness: Achieving Wellness while Living with MS National Education Session May 28, 2011 Question Period I’l start with a written question. Can you give us examples of strategies for coping with changes? That’s quite a question