Seizure - Emergency Action Plan

Seizure - Emergency Action Plan

HCS Health Services
Student Information
Student Full Name
Date

MonthDayYear
Date
Current Grade Level
School
Teacher
Does your student ride a bus?
Morning Bus Number
Evening Bus Number

Emergency Contact Information
Contact 1
Full Name
Contact 1 Full Name
Phone Number - 1
Contact 1 Phone 1Format: (000) 000-0000.
Phone Number - 2
Contact 1 Phone 2Format: (000) 000-0000.
Phone Number - 3
Contact 1 Phone 3Format: (000) 000-0000.
Contact 2
Full Name
Contact 2 Full Name
Phone Number - 1
Contact 2 Phone 1Format: (000) 000-0000.
Phone Number - 1
Contact 2 Phone 1Format: (000) 000-0000.
Phone Number - 1
Contact 2 Phone 1Format: (000) 000-0000.

Seizure Information
Seizure Type
Normal Length / Frequency
Seizure Triggers or Warning Signs
Daily Medication for Seizures
Does Student Have A Vagal Nerve Stimulator?
Does Student Have An Emergency / Rescue Medication?
If Yes, Please Provide the Name of the Medication
Emergency Medication to be Given for Seizures Lasting Longer Than Number of Minutes Minutes.
Emergency Medication is stored at Location of Medication

Signature and Understanding
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?
Parent / Guardian Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty: