ADD/ADHD

Medication Information
Medications the student is taking at home
Separated by commas
Student will be taking Medication at school and should report to the Location daily at Time .

If You See This:	Do This:
Loss of appetite, weight loss, persistent headache or stomachache, occasional motor tics & nervousness	Notify school nurse for monitoring, as these are common side effects, especially when initiating new meds or changing doses. Notify parent if persists or of great concern.
Persistent and frequent motor or vocal tics: Motor- rapid repetitive muscle movements such as eye blinking, shoulder shrugging, head jerking, facial twitching or other movements Vocal- sniffing, snorting, throat clearing, coughing, verbal outbursts, grunting, barking, repeating words or stuttering	Notify school nurse and/or parent immediately for follow up with physician. Teacher may keep a log of occurrences of tics.
Continued signs of inattention, impulsivity, and/or hyperactivity	Report specific incidents/behaviors to parents and nurse.

Signature and Understanding
I understand and agree that per WVDE Medication Policy 2422.8:
1. I (or an adult delegate) must deliver all medication to the office and sign it in on the medication log.
2. Agree never to send the medication with my child.
3. Agree to supply refills in a prompt manner when notified, to avoid missed doses.
I understand and agree that information in this Emergency Action Plan will be shared with appropriate school staff.
Are you able to provide your signature on this form?

Yes, I am able to provide my signature on this form.No, I am NOT able to provide my signature. Note: You will need to come to the school and sign in person.
Parent / Guardian Signature

Clear
Today's Date

MonthDayYear
Should be Empty:

ADD / ADHD Emergency Action Plan