Holly Area School District
Asthma Emergency Care Plan
Student Name: ____________________________________________________ DOB: ____________________
Teacher: ________________________________ School Building: __________________ Grade: _______
Asthma Triggers: (check all that apply)
[] Weather changes [] Illness [] Exercise [] Smoke [] Odors
[] Allergies; cat, dog, dust, pollen, mold, etc. [] Emotions; stress [] Other: ______________
Describe the symptoms experienced before, during, after asthma attack:
(Check all that apply)
[] Cough [] Shortness of Breath [] Wheezing [] “Tightness” in chest [] Breathing
hard/fast [] Runny Nose [] Rubbing/itching of chin/neck [] Fatigue [] Other: _________
TO BE COMPLETED BY PARENT/GUARDIAN
Please provide emergency information and relationship to the student.
Contact # 1: _____________________________________________ Phone #: __________________________
Contact # 2: _____________________________________________ Phone #: __________________________
Contact # 3: _____________________________________________ Phone #: __________________________
Preferred Hospital: __________________________________________________________________________
*In the event of an asthmatic emergency, I agree to the emergency care plan established by my
student’s Authorized Prescriber, and I agree to release the school district and its personnel from
all claims of liability if my student suffers any adverse reactions. I also agree to furnish the
correct medications to the school in accordance with this care plan. I understand that by
signing this document, I give permission for my student’s Authorized Prescriber to share
information about the prescribed medications and/or conditions listed here.
Parent/Guardian Name: ___________________________________________ Date: __________________
*Parent/Guardian Signature: _______________________________________________________________
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Fax this signed care-plan to: _________________: Attention School Nurse.
There MUST be one Medication Authorization Form filled out for each medication
prescribed.
Please provide an extra set of medications, labeled properly and not expired to be
kept in the school office for back up purposes.
* The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school
nurses, physicians, or other health care providers for treatment purposes, without the authorization of the
student or student’s parent. For example, a student’s primary care physician may discuss the student’s
medication and other health care needs with a school nurse who will administer the student’s medication
and provide care to the student while the student is at school. See 45 CFR 164.512(b)(1)(vi). Updated
9/19/13 http://www.hhs.gov/ocr/privacy/hipaa/faq/ferpa_and_hipaa/517.html
Holly Area School District
October, 2015 rev. 2 pages.
Asthma Emergency Care Plan
Student Name: ____________________________________________________ DOB: ____________________
Teacher: ________________________________ School Building: __________________ Grade: _______
TO BE COMPLETED BY PHYSICIAN OR AUTHORIZED PRESCRIBER
If exercise induced as preventative:
[] Give 2 puffs of Quick Relief Medication 15 minutes before physical activity. (Gym class, exercise/sports,
recess)
[] Repeat in 4 hours if needed for additional or ongoing physical activity.
[] Other: _______________________________________________________________________________________________________________________
Immediate Action is needed if student has:
 Trouble breathing; shortness of breath
 Wheezing and/or coughing
 Tightness in the chest
[] Stay with Student and make sure student remains in an upright position.
[] Give Quick Relief/Rescue medication as ordered.
[] Call Parent/Guardian.
[] If no improvement within _________ minutes, repeat use of medication as ordered.
[] Student may resume normal activities once feeling better
OR
Emergency Action is needed if student:
 Does not respond to Quick Relief/Rescue Medication.
 Condition worsens:
 Gasping for breath; struggling to breath; hunched over
 Lips and/or fingernails are blue or gray
 Skin of chest and/or neck pull in with breathing
 Decreased level of consciousness
[] CALL 911
[] Remain with student and remain calm
[] Encourage student to breath in through nose and out through mouth
[] Contact parent/guardian. School personnel should accompany student to the hospital if no
parent/guardian available.
[] Refer to Allergy/Anaphylaxis Care Plan for Epinephrine if ordered
[] Prepare to do CPR
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Quick Relief/Rescue Medication name: _______________________________________________________________________
2 puffs via: [] Inhaler [] Spacer [] Mask [] Other: _____________________________________________________________
[] This medication must be carried on the student’s person at all times.
[] This medication must accompany student on field trips.
[] This medication must accompany student on the bus.
[] This medication must accompany student for school related extracurricular events such as sports, clubs, etc.
The student is both capable and responsible for self-administering of this/these medication(s):
[] Yes, supervised [] Yes, unsupervised [] No
Prescriber’s Name & Credentials: _____________________________________________ Date: ______________
*Prescriber’s Signature: ________________________________________ Phone #: __________________________
October, 2015 rev. 2 pages.