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 Phone
Parent/Guardian Email:
Additional Emergency Contact
Contact Phone
Contact Email
Asthma Severity: Intermittent or Persistent:  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 Inhaled -agonist
 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)
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.
Call 911 or go directly to the
Peak flow: < _______
Emergency Department NOW!
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 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 1. _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ 3. _________________________________________________________________________________________________ 4. _________________________________________________________________________________________________ 5. _________________________________________________________________________________________________


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