AVENTURA CITY OF EXCELLENCE SCHOOL
3333 N.E. 188th street • Aventura, Florida 33180
. (305) 466-1499 • Fax: (305) 466-1339
Eric M. Soroka
Citv Manager
June 29, 2016
RE:
Required Medical Forms
JulieAlm
Principal
Dear Parent(s),
All students that require medications to be dispensed at ACES must have the applicable
forms on file and will need to be updated annually prior to the start of each new school
year. The State of Florida Health Department now requires forms for specific type
diagnosis for students to be on file besides the CSUSA "Authorization for Medication "
form. The below forms are required where applicable:
•
•
•
•
•
•
FM #0101: (ACES: "Student Allergy Information") - List only allergies where the
child does not require any medications to be dispensed at ACES. (1-page)
FM #0102: (CSUSA: "Authorization for Medication") - If your child requires
medication to be dispensed at ACES. (1-page)
o PLEASE USE CSUSA FORM, WE CANNOT ACCEPT ANY OTHER
FORMS FOR IfA UTHORIZA TION FOR MEDICA TlON".
FM #0103: (Health Department: "Asthma Action Plan") - If your child has
asthma. (1-page)
FM #0104: (Health Department: "Diabetes Management Plan") - If your child
has diabetes. (2-page form) Parent must attach a letter stating they take full
responsibility as acting nurse as ACES does not have a nurse on premises.
FM #0105: (Health Department: "Seizure Action Plan") - If your child has a
seizure disorder. (1-page)
FM #0106: (Health Department form: "Severe Allergy Action Plan") If your
child has a severe allergy that requires an EPI-PEN or AUTO-INJECTOR.
(1-page)
You must ensure the above-mentioned applicable form(s) are completed for each child
and signed by the child(ren's) physician and parent or legal guardian before submitting
applicable forms to ACES . All forms can be downloaded on ACES website at
www. aventuracharter.org under the tab Parents/Forms, documents,
resources/medical forms.
Please keep in mind that ACES cannot dispense or hold medications until these forms are
completed, signed and submitted to ACES . All forms are to be submitted to the
Elementary Front Desk just prior to the start of the new school year.
We look forward to another great year of excellence at ACES!
www.aventuracharter.org
A Service of the City of Aventura
2016-2017
ACES Student Allergy Information
Complete this form onl or aller ies that DO NOT
~uire medications to be dispensed at ACES.
If your child requires medications to be dispensed at ACES you will need to complete
CSUSA's Medication Form and if applicable the Florida Health Departments Medication form
for Asthma, Diabetes, Epilepsy & Medications that require an EPI-PEN/AUTO-INJECTOR. Do
not put allergies on this form if your child requires these forms.
Student Name:
_
HRTeacher:
Grade:
_
Allergies:..-:
_
Parent Name:
Cell Phone:
_
_
Home Phone:
_
Please submit this form to the Elementary
Front Desk as soon as possible.
I FM #: 0101 I
Authorization for Medication
Nameof Student:
Date of Birth:
Grade:
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
MEDICATION TREATMENT PLANTO BE COMPLETED BY PHYSICIAN
Name of Medication,Dosage, SpecificTimes & Directions(including start and end of prescription date) for Administration:
Note:
Medication must be supplied in the original container. Ask pharmacist to divide the medication into two completely
labeled containers, providing one for home and one for school.
Side Effects I Special Instructions:
_
YES
Is the student required to carry this medication with him/her?
NO
(Note: School Policy is that all medicationshould be turned in to the front office unless specified by the Physician.)
Note to Physicians:
Please complete treatment plan on the back of this form lor students who require any special health
proceduresduring school hours; i.c, Inhalers, nebulizer treatment, catheterization,auctioning tube feedings, glucose testing,etc.
Printed Name or Stamp of Physician
Physician's Signature
Physician'S Phone Number
Physician's Fax
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
PARENTAL PERMISSION TO BE COMPLETED BY THE PARENT I GAURDIAN
I grant the principalor his/her designee the permission to assist in the administration of each prescribed medication I procedure 10
be providedduring the school day, including when
is away from school property on official
school business.
Name of Student
I understand that my signature relieves schoolpersonal of any and all liability related to the administration of the prescribed
medication.
Signature of Parent
Date
Home Phone Number:
Work PhoneNumber:
Other PhoneNumber:
c..:
II
\ ~ I 1' 1.
I' 'i.
<;
. .. .. I l l ' t '
~
;.;
Putting Studt'nb First
FM #: 0102
••
T
AMERICAN
LUNG
ASSOCIATION.
AsthmaAction Plan
General Information:
• Name
_
• Emergency contact
Phone numbers
• Physlclanlheallhcare provider
Phone numbers
_
• PhysIcian signature
Date
_
_
Severity Classification
o Inlermittent
o Mild Persistent
• "
",
"
•
•
o Colds o Smoke
o Exercise o Dust
o Animals o Food
o Other
0 Moderate Persistent
0 severe Persistent
"
, '.
•
~ .
'.
•
•••
,
.
',
.
.
'
"
•
'
0 Weather
0 AIr PolluUon
1. Premedlcallon (how much and when) _ _
2. Exercise modfllcalloJ\S
,
'
.
',
~
'
:.
•
.,.
.
Green Zone: Doing Well
Peak Flow Meter Personal Best
Symptoms
Control Medications:
•
•
•
•
BreathIng Is good
No cough or wheeze
can work and play
Sleeps well atnight
. Peak Flow Meter
More than 80% ofpersonal best or
X~.IJ.~w .~o.~ ~: ~~II~~ "':'-~r.~f! __.__
Symptoms
• Some problems breathing
• Cough, wheeze, or chest tight
• Problems \'/or1<lng or playing
• Wake atnight
Peak Flow Meter
Between 50% and 80% of personal best or
_ _ _ _ 10
_
MedIcine
'
=
.
:
•
:
How Much to Take
•
:
...
:
~.
\
r
~ :.,
•
•
•
c
.
.~
When to Take It
_
~C?~tact phy.slcia~_ rf _':I.s.~~_g_~lJ_r_~~ ~eU.e.! ,!,or~ than 2 ti~~~ .per ~~~.k.-_ ,
Continue control medicines and add:
How Much to Take
Medicine
IF your symptoms (and peak flow, If used)
return to Green Zone afterone hour of the
quick-relief treatment, THEN
o Take QuIck-relief medication every
4 hours for 1 to 2 days.
o Change your long-term conlrol medicIne by
o Contact your physician for folloW-Up care.
o call your physlclanIHealthcare pro~der
within __ hour(s) ofmodifying your
medication rouUne.
Ambulance/Emergency Phone Number:
Symptoms
• LoIS ofproblems breathing
• cannol worK orplay
• Getting worse Instead ofbetter
• Medlclne isnot helping
Continue control medicines and add:
Medicine
When to Take It
IFyour symptoms (and peak flow, If used)
DO NOT return to Green Zone afterone
hourof the qulck-rellel treatment, THEN
o Take quick-relief treatment agaIn.
o Change your long-term control medIcine by
Red Zone: Medical Alert
Peak Flow Meter
Less than 50% ofpersonal best or
_ _ _ _ 10
_
_
_
How Much to Take
When to Take It
Go to thehospllal orcallfor anambulance If: Call anambulance Immediately If the
o Stili Intne red zone after 15 minutes.
o You have not been able to reach your
o
physlclanlheallhcare provider for help.
71
_
following danger signs are present:
o Trouble walklngltalking due toshortness
of breath
o Ups ornngemails are blue.
Re'cJuly_2008
FM # : 0103
•
,
Student's Name:
,Date of BIrth:
School Name:
Grade
DIabetes OType 1 ; OType 2 Dale of DIagnosis :
Homeroom
CONTACT INFORMATiON
ParenVGlIardlan #1:
_
Plan Effective Date(s) :
Phone Numbers: Home
Wolk
C,elUPager
PsrenVGlIardlan #2:
Phone Numbers: Home
Work
Cell/Pager
Diabetes Healtheare ProvIder
Phone Number;
Other Emergency Contact
Relallonshlp:
_
_
_
Phone Number: Home
Work/CeUPager
EMERGENCY NOTIFICATION: Notify parents of the following conditions (If unable to reach parents. call Diabetes Healthcare Providar Hsled above)
a. Loss of consdousness or seizure (convelslon) Immediately elter Glucagon given and 911 called.
b. Blood sugars In excess of
mgldl
c. Positive urine ketones.
d. Abdomlnel pain. nausealvomitlng. diarrhea, fever, altered breathing, or altered level of consciousness.
0 Detennlne correct portions and number of carbohydrate serving
MEALS/SNACKS: Student can:
TlmelLocatlon
Food Content and Amount
o
Mid-afternoon
Midmorning
o
Before PE/Acllvlty
Lunch
DAfter PElAclMIy
o
o
Breakfast
o
0 Calculate carbohydrete grams accuretely
Tlme/Looatlon
Food Content and Amount
If outside rood tor party or food sampling provided to class:
Type of Meter:
BLOOD GLUCOSE MONITORING AT SCHOOL: 0 Yes 0 No
_
If yes. ean student ordlnartly perform own blood glucose checks? DYes 0 No; Interpret resulls oYes ONo; Needs supervision? UYes eNo
0
Time to be performed:
o
o
Before breakfast
MIdmorning: before snack
Before lunch
Dismissal
0
Classroom
o
Place 10be performed:
o
OPTIONAL: Target Range for blood glucose:
o Before PEJActivily Time
DAfter PElActivlty Time
o Mlcl-aflemoon
o As needed for signs/symptoms of lowlhlgh blood glucose
CUnlcIHealthRoom
0 Other
...!mgldlto
0 Yes
INSULIN INJECTIONS DURING SCHOOL:
0 No
0 Perenl/Guardlan elects to give Insulin needed at school)
Detennlne correct dose?
DYes ONo
Draw up correct dose? DYes DNo
Give own InJection?
DYes ONe
Needs supervision?
If yes. can student:
Insulin Delivery: 0 SyringeMal 0 Pen
DYes ONo
0 Pump (If pump worn. use 'SuDolementallnfonnatlon Sheet for Student Wearlna an Insulin Pump')
Standard dally Insulin at school:
0 Yes
Type:
Time to be given:
Dose:
_
...Jmgldl (Comp/eted by Dlebetes Hea/lhcare ProvIder).
0 No
DYes
coaecUon Dose of Insulin for II/ph Blood Glucose:
ONo
If yss: ORegu!ar DHumalog ONovolog Time to be given:
o Detennlne dose per slidIng scale below (In units):
_
o Use formula:
Blood sugar.
Insulin Dose:
_
Calculate Insulin dose for carbohydrate Intake: DYes ONo
(Blood glucose ­
Blood sugar.
Insulin Dose:
_
--------') +
If yes, use: ORegular OHumalog ONovolog
Blood sugar.
Insulin Dose:
_ _ _" un\l(8) per
Blood sugar.
_ Insulin Dose:
Blood sugar:
Insulin Dose:
o
grams Carbohydrate
Add carbohydrate dose to correction dose
OTHER ROUTINE DIABETES MEDICATIONS AT SCHOOL: DYes
Name of Medication '
Dose
_
_
----- =
units 01insulin
0 No
TIme
Route
Possible SIde Effects
EXERCISE, SPORTS, AND FIELD TRIPS
Blood glucose monitoring end snacks as ebove. Quick access to sugar-free liqUids, fast-ecUngcarbohydrates, snacks. and monitoring equipment
A fast-acUng carbohydrale such 8S
should be aveliable althe site.
Child should nol exercise If blood glucose level Is below
mgldl OR If
SUPPLIES TO BE FURNISHEDIRESTOCKED BY PARENT/GUARDIAN: (Agreed-upon locatlons noted on emergency card/nursing care plan)
o
o
o
Blood glucose meterlstrlpsJlancelsllancing devIce
Ketone testing slrips
Sharps container for dassroom
o
o
o
Fasl-acllng carbohydrete
Carbohydrate-contalnlng snacks
Carbohydrate free beverage/sneck
_
o
o
o
Insulin vIals/syringe
Insulin pen/pen needles/cartr1dgss
Glucagon Emergency KIt
Page 1 of2
73
FM #: Ol04-page 1
mg/dl)
MANAGEMENT OF HIGH BLOOD GLUCOSE (over
v'Usual sIgns/symptoms for this student:
0
Increased thirst. urination, appetlle
0
Tiredness/sleepiness
0
Blurred vision
0 Warm, dry, or nushed skin
0 Other
Indicate treatment choices:
Sugar-free fluids as tolerated
Check urfne kelones If blood glucose over
mgldJ
Notify parant lt urine ketones posiUve.
May not need snack: ca/I parent
See 'Insulin InJections: Correction Dose of Insulin for High Blood Glucose"
Other
o
o
o
o
o
o
MANAGEMENT OF VERY HIGH BLOOD GLUCOSE (over
mgldl)
Indicate treatment choices:
Carbohydrate-free fluids Ir tolerated
Check urine for ketones
Notify parents per "Emergency Notification" eectlon
0 II unable to reech parents, cell diabetes cere provider
o Frequant bathroom privileges
Slay with student end document changes In status
0 Delay exercise.
D Other
v'Usual slgns/symploms for this sludent
0
Nausea/Vomlting
0 Abdominal pain
0
Rapid, shallow breathing
0
Extreme thirst
0 Weakness/muscle aches
0 Fruity brealh odor
D Other
o
o
o
o
mgldl)
MANAGEMENT OF LOW BLOOD GLUCOSE (below
v'Usual signs/symptoms for this child
Indicate treatment choices:
D Hunger
o
o
D
o
o
o
D
D
D
o
o
D
o
o
o
If student /s awake and able to swallow,
Change In personalltylbehavlor
Paleness
Weakness/shakiness
Tiredness/sleepiness
Dizziness/staggering
Headache
Rapid heartbeat
NauseaJloss or appetite
Clamminess/sweating
Blurred vision
Inallenllonlconfuslon
Slurred speech
Loss of conscJousness
Seizure
Other
give
0
0
0
0
0
grams fast-seling carbohydratesuch as:
4oz. Fruit Juiceor non-dlet soda or
3-4 glucose tablets or
Concentrated gel or tube Irosting or
8 oz. Milk or
Other
Retest BG 1G-15mlnutes aller treatment
Repeat treatment unlil blood glucose over 80mgldl
Follow treatment with snack or
It more than 1 hour tUi next meaVsnack or If going to activity
Other
o
IMPORTANTII
If student Is unconscious or havlng, seIzure. presume the student Is havIng a low blood glucose and:
Call 911 Immediately and notify parents.
D
Glucagon
D
Glucose g811 tube can be administered Inside cheek and massaged from outside while awaiting or during
administration of Glucagon by staff member at scene.
D
Glucagon/Glucose gel could be used If student has documented low blood sugar and
swallow.
%mg
or
1 mg (circle desired dose) should be given by trafned personnel.
Is vomiting or unable to
Student should be turned on hlslher side and maIntaIned In thIs "recovery" position till fully awake".
SIGNATURES
Itwe understand that aJltreatments and procedures may be performed by the student and/or trained unlicensed asslstlve personnel \'IIthln the school orby
EMS In the event 01los8 or consciousness or seizure. I also understand that the school Is not responsible for damage, loss of equipment, or expenses
utilized in these treatments and procedures. I have reviewed this Intormatlon sheat and agree wllh the Indicated Instructions. This form will assist the
school health personnel In developing a nursIng care plan.
Parent's SIgnature:
Date:
Physician's Signature
Date:
School Nurse's Signature:
Date:
Thisdoeumsntfollows /he gU/dlng princ/ples ouUlned by the American Diabetes AssociaUOII
Revised December 5, 2003
DIabetes Modical Management Plan! Florida Govemor's Diabetes Advisory Council
Page20t2
74
FM #: 0104 Page 2
J)j EPILEPSY
'!. FOUNDATJON$
Seizure Action Plan
•
Effective Date
This student Is being treated for a seizure disorder. The Information below should assist you If a seizure occurs during
school hours.
Student's Name
Date of Birth
Parent/Guardian
Phone
Cell
Other Emergency Contact
Phone
Cell
Treallng Physician
Phone
--- --:-:~-;;--...,.-:-c;_:_~---------------------- .-------.----------
Signilicant Medical History
SeIzure Information
SeizureType
Lenglh
Frequency
Description
Seizure t(lggers or warning signs:
Student's response after a seizure:
Basic First Aid: Care & Comfort
Please describe basic first aid procedures:
0
Does student need to leave the classroom after a seizure?
If YES, describe process for returning student to classroom:
Emergency Response
A "seizure emergency'" for
this student Is defined as:
o
Yes
No
Seizure Emergency Protocol
(Check all thatapply andclarifybelow)
o
o
o
o
o
o
.
Contact school nurse at
Call 911 for transport to
Notify parent or emergency contact
Administer emergency medications as indicated below
Notify doctor
Olher
Basic Seizure First Aid
Slay calm & lrack lime
Keepchildsafe
Do not restrain
Do not put anything In moulh
Slay with child until fully conscious
Record seizure In log
For tonic-clonic seizure:
• Protect head
• Keep airwayopenlwatch breathing
• Turn childon side
•
•
•
•
•
•
A seizure Is generally
considered an emergency when:
• Convulsive (tonic-clonic) seizure lasts
longerthan5 minutes
• Student has repeated seizures without
regaining consciousness
• Studentis injured or hasdiabetes
• Student has a flrst-lime seizure
• Student has breathing dlfficull1es
• Student has a seizure In water
Treatment Protocol During School Hours (Include dally and emergency medications)
Emerg.
Med. ./
Dosage &
Time of Day Given
Medication
Does student have a Vagus Nerve Stimulator?
0
Common Side ENects & Special Instructions
Yes
0
No
If YES, descrlbe magnet use:
Special Considerations and Precautions (regarding _school activities, spor_ts, trips, etc.)
Describe any special considerations or precautions:
Physician Signature
~_
_
Parent/Guardian Signature
~~~_~_ _~_~~~_~_~
Date
Date
DPCm
FM #:
0105
SEVERE ALLERGY ACTION PLAN
FOR SCHOOL PERSONNEL
Student:
Teacher:
DaB:
----------- Classroom:
- - - - -Grade:
SEVERE ALLERGY TO:
_
Auvl-Q Epinephrine Auto-inlectorTralned Staff:
Name (Please print)
Title
Sinnature
.­
Nurse Verification:
Action plan and staff training verified.
Nurse slgnature
Date,
_
Parent/guardian signature
Date
_
1. pun Auvi-Q from the outer case
and follow the voice instructions
(do not proceed to step 2 unlil you are ready to use Auvi-Q. If not ready to use, replace the outer case.)
2. Pull off Red safety guard (The safety guard is meant to be tight. Pull firmly to remove.)
3. Place black end against the middle of the outer thigh (through clothing, if necessary), then press firmly
4. and hold in place for 5 seconds
.
."
j;
~ _ .~ ~.t
.
o
..
.
Ao
II
5. Note: Auvi-Q makes a distinct sound (click and hiss) when activated. This is normal and indicates Auvi­
Q is working correctly.
6. Call 911 or seek emergency medical attention.
7. Deliver used Auvl-Q Epinephrine Auto-Injector to EMS responders.
8. Deliver used Auvi-Q (epinephrine injection) to EMS responders.
Revised 07/2014
Form adopted from the Food Allergy & Anaphylaxis Care Plan.
59
FM #:
0106