Inhaler portable device used to inhale medication used to treat diseases of the respiratory system.
Inhaler. No direct monitoring will be conducted by the school staff. The student is responsible for self-administration of the inhaler. If the student continues having difficulty breathing, he/she should report to the office and the parents will be notified by the appropriate school staff. Self-administered emergency epinephrine: No direct monitoring will be conducted by the school staff. The student is responsible for notifying school staff in the event he/she had the need to self- administer the emergency medication. It is the parents’ responsibility to immediately notify the school if the child’s health status changes, or when a change in physician and/or medication occurs. Changes in procedure must be received in writing from the physician authorizing treatment. This agreement must be renewed at the beginning of each school year or whenever there is a change in medication. The district is not responsible for any risk involved with improper handling of this medication including overuse, improper administration, breakage, theft, loss, sharing, playing with or careless storage of the medication. Permission to self-medicate may be revoked if the student violates the school district policy governing Administering Noninjectable Medicines to Students and/or these regulations. Additionally, students may be subject to discipline, up to and including expulsion, as appropriate. To be completed by the physician: The above named student has been instructed in the proper use of their asthma inhaler or medication. The child’s well-being is in jeopardy unless this medication is carried on his/her person. Therefore, I request that he/she be permitted to carry the medication at school. He/she is capable to self-administering the medication, understands the purpose, appropriate method, and frequency of use of the medication/inhaler. PHYSICIAN’S SIGNATURE: DATE: PRINTED/TYPED NAME OF PHYSICIAN To be completed by the parent/guardian: I permit my child to carry the above listed asthma inhaler or medication as ordered by his/her doctor. I also specifically release the school district and all school personnel from any and all civil liability if my child suffers an adverse reaction as a result of self-administering medication during school hours PARENT /GUARDIAN SIGNATURE: DATE: To be completed by the student: I agree to take my medication as instructed by my doctor. I understand that using my medication in a manner other than directed by my doctor (ex sharing with other students...
Inhaler. My child will require the following plan or other treatment at school (Check all that apply) Student Allergy/Anaphylaxis Action Plan Asthma Action Plan Diabetes Care Plan Diabetes Care Plan with pump Seizure Action Plan Other treatment in school USE THIS SIDE IF YOUR CHILD HAS A MEDICAL CONDITION(S) NOT LISTED ON FRONT PAGE (CHECK ALL THAT APPLY) Head Parent/Guardian Signature Date Alopecia (hair loss) Disfigurement/Head Encephalitis (Brain inflammation) Epilepsy/Clonic/Tonic Epilepsy/Jacksonian Epilepsy/Petit mal Febrile Seizure Hydrocephalus Meninges Tumor/Benign Shunt Eyes Amblyopia (lazy eyes) Artificial Globe Color Blindness Congenital Congenital Cataracts Xxxxx’s Retraction (eye movement disorder) Esophoria (eyes turn inwards) Exophoria (eyes turn outwards) Glaucoma, congenital Hypermetropia (longsighted) Intraocular lenses Ptosis (drooping eyelid) Retinitis Pigmentosa (damaged retina) Retinoblastoma Retinoschisis, Juvenile Stargardt's Disease (early macular degeneration) Ear/Nose/Mouth/Throat/Neck Xxxx’x palsy (facial paralysis) Cervical Joint Disease Cleft Palate Epistaxis (nosebleed) Hearing/Condition Sensorineural Meniere's Syndrome (inner ear disorder) Microtia (small outer ear) Pain, neck Polyp, larynx Respirator dependent Trach/Obstruction Trach/Stoma Problem Tracheomalacia Vertigo (dizziness) Heart/Lungs/Brain Aortic Stenosis Atrial Septal Defect Breathing Exercises Breathing, Bronchial Bruit Congestive Heart Failure Cardiac Valve Disease Cardiomyopathy Hemiparesis Kawasaki Disease Mitral Valve Prolapse Pacemaker, Cardiac Paroxysmal Tachy (AV) Patent Ductus Arteriosus Pulmonary Hypertension Pulmonary Stenosis Pulmonary Tuberculosis Suctioning/aspirator Tachycardia Tuberculosis Miliary Transposition Great Vessels Vasovagal Syncope Ventricular Septal Defect Ventricular Tachycardia Xxxxx‐Xxxxxxxxx‐White Syndrome Abdomen/Genito‐Urinary Bladder Extrophy Celiac Disease Chronic Renal Failure Colitis Cystic Disease Medulla Dialysis, Renal Duodenal Spasm Dysmenorrhea Dyspepsia (impaired digestion) Esophageal Reflux Esophagus stricture Gastroschisis GT/Stoma Malfunction Hepatitis Hepatitis B Carrier Hepatitis C Carrier Hiatal Hernia Hirschsprung’s Disease Ileostomy Irritable Bowel Syndrome Jejunostomy Kidney Removed Kidney Transplant Nephritis Nephrotic Syndrome Neurogenic Bladder Polycystic Kidney Short Bowel Syndrome Suprapubic Catheter Transplant, Liver Ulcer, Gastric Ulcer, Peptic Wilms' Tumor Bone/Muscle/Joint Amputation below knee Arthritis, Chro...
Inhaler
