ASTHMA ACTION PLAN FORM
An asthma action plan form only needs to be completed if your child requires asthma medications (inhaler/nebulizer) while in school. It provides both doctor’s orders AND a doctor prescribed plan of care that details how the school nurse should proceed should your child present with asthma symptoms.
Please make sure to have the doctor complete ALL portions, sign, and stamp the form where indicated. Parent signatures are required on the bottom of the first page and also on the second page of the asthma action plan. BOTH signatures are required in order for the school nurse to administer these medications to your child. If a signature is missing, the medication may not be administered to your child.
*A signed medication policy form is required. Please refer to the Medication Policy Form page.
*A physician order form is NOT required for your student to receive asthma medications. The asthma action plan serves as both the physician’s orders and plan for your child.
All medications must be brought to school by an adult in the original store or prescription container. Please do not send your child to school with medications for safety reasons and as per our medication policy. Please check all expiration dates and make sure the medication is not expired. Medications must be picked up by an adult at the end of the school year. They will not be sent home with your child. Any medications not picked up by the end of the school year will be discarded.
Download link is at the bottom of the page. English and Spanish versions are available.