Place student pic
Belton ISD Health Services
Emergency Plan for Bleeding Disorder
Guidance for Non-licensed School Personnel
20__-20__ Campus:
Student
DOB
Current meds to treat bleeding disorder
Date of last hospitalization
Bleeding Disorder Emergency Medication needed at
school:
Medication at school:
N/A
Minor Symptoms
If You See Any Of These:
 Minor cut or scrape
 Minor bruising
 Nose bleed
Dosage/Route
BISD ID #
Times
GRADE/HR
Physical Restrictions:
No
Yes (explain):
Expiration Date
In Health Office
At Home
ACTIONS TO TAKE IN AN EMERGENCY
Do This:
 Stop activity
 For minor cut/scrape: Cleanse with soap and water, apply
firm pressure, apply clean bandage
DO THIS
 For minor bruising: Apply firm pressure and ice to site
 For nose bleeds: Apply firm uninterrupted pressure by
pinching nose for 5-20 min
 **Student may need rescue/prescribed medication
 Call the nurse/ office for assistance
 Stay with student- DO NOT LEAVE ALONE
Severe Symptoms
Do This:
If You See Any Of These:
 Call or have someone CALL 911
 Coughing up or vomiting fresh or dark
brown material
 If the student can drink, have him/her drink fluids to flush
kidneys/bladder
 Stomach pain with weakness or
paleness
 **Student may need rescue/prescribed medication
 Bright red or cola colored urine
 Call the nurse/office for assistance
 Any injury near the eye and complains
 Start CPR if indicated
of changes in vision or pain
CONTACT PARENT AS SOON AS POSSIBLE
 Any injury to the head which produces
changes in personality, changes in
level of consciousness, stiff neck,
DO THIS
headache, forceful vomiting
THE SIGNS AND SYMPTOMS ABOVE MAY
BE EVIDENCE OF BLEEDING AND SHOULD
NOT BE TAKEN LIGHTLY.
Additional instructions:
PHYSICIAN/PARENTAL AUTHORIZATION FOR EMERGENCY PLAN FOR BLEEDING DISORDER
Physician authorization: Print Name
Physician Signature
Physician Phone
Date
I grant permission to BELTON ISD to administer this medication to my child. I am giving permission to BISD staff to contact my physician
for additional information if necessary. If the school nurse deems it necessary, I grant permission to notify my child’s teacher(s) of his
health condition. I understand that a medically untrained designee of the principal may give the medication.
Parental Authorization: Signature
Best emergency phone
Emergency Contact
Phone
Plan Developed by(nurse):
Caregiver Trained
Other phone
Date
Other phone
School Use Only
Date
Caregiver Trained
Date
Date
Caregiver Trained
Date
Reviewed 7/13/cs
Place student pic
Belton ISD Health Services
Emergency Plan for Bleeding Disorder
Guidance for Non-licensed School Personnel
20__-20__ Campus:
Student Name
DOB
BISD #
Grade/Homeroom Bus #
Bleeding Disorder: Care Plan Review
Printed Name
Signature
Position/Relationship
Date
Instructor
Initials
Reviewed 7/13/cs