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 1
Phone Number - 2
Contact 1 Phone 2
Phone Number - 3
Contact 1 Phone 3
Contact 2
Full Name
Contact 2 Full Name
Phone Number - 1
Contact 2 Phone 1
Phone Number - 1
Contact 2 Phone 1
Phone Number - 1
Contact 2 Phone 1

Seizure Information
Seizure Type
Normal Length / Frequency
Seizure Triggers or Warning Signs
Daily Medication for Seizures
Does Student Have A Vagal Nerve Stimulator?

YesNo
Does Student Have An Emergency / Rescue Medication?

YesNo
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?

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
Date
Should be Empty: