School Action Plan For Students With Asthma

Academic Year: 2019-2020
Which division of the school is the student in? *
Emergency contact number(s) for parent/guardian listed in priority order. [Ex.503-246-7771 mom cell]
[use the plus (+) symbol to add up to 2 more rows to the list]
Does your child use a peak flow meter? *
Does your child need to pretreat with an inhaler before exercise? *
Do you authorize your child to carry
an inhaler in their backpack? *
Are medications needed to control the asthma? *
Please list medications -[use the plus (+) symbol to add more rows to the list]
Does your child ever ride the
OES bus to or from school? *
The electronic signature below indicates that, as the parent or guardian of the above named student, I authorize an exchange of information to occur between the OES nursing staff and the physician or health care provider listed above.