SEIZURE ACTION PLAN (SAP)
EPILEPSY FOUNDATION
Student Name
*
Student Birth Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
Parent/Guardian Phone
*
Format: (000) 000-0000.
Emergency Contact/Relationship
Emergency Contact Phone
Format: (000) 000-0000.
Seizure Information
Rows
Seizure Type
How Long It Lasts
How Often
What Happens
How to respond to a seizure (check all that apply)
First aid - Stay. Safe. Side.
Give rescue therapy according to SAP
Notify emergency contact
Call 911
Other
First Aid for any seizure
Stay calm, begin timing seizure
Keep safe, remove harmful objects, don't restrain, protect head
Turn on side if not awake, keep airway clear
Stay with student until recovered from seizure
Other
WHEN TO CALL 911
Seizure with loss of consciousness longer than 5 min, not responding to rescue meds if available
Repeated seizures longer than 10 min, no recovery between them, not responding to rescue meds if available
Difficulty breathing after seizure
Serious injury occurs
When to call provider first:
Change in seizure type or pattern
Person does not return to usual behavior (confused)
First time seizure that stops on its own
Other medical problems
When rescue therapy may be needed:
If seizure (cluster, # or length)
Name of Med/Rx
How much to give (dose)
How to give
If seizure (cluster, # or length)
Name of Med/Rx
How much to give (dose)
How to give
Care after seizure
What type of help is needed? (describe)
When is person able to resume usual activity?
Special instructions for first responders:
Daily seizure medicine
Rows
Medicine Name
Total Daily Amount
Amount of Tab/Liquid
How Taken (time of each dose and how much)
Other information
Triggers
Important Medical History
Allergies
Epilepsy Surgery (type, date, side effects)
Devise;
VNS
RNS
DBS
Date Implanted
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diet Therapy
Ketogenic
Low Glycemic
Modified Atkins
Other (describe)
Special Instructions
Health care contacts
Epilepsy Provider
*
Phone
*
Format: (000) 000-0000.
Primary Care
*
Phone
*
Format: (000) 000-0000.
Preferred Hospital
Phone
Format: (000) 000-0000.
Pharmacy
Phone
Format: (000) 000-0000.
Parent signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2020 Epilepsy Foundation of America, Inc.
Revised 01/2020 130SRP/PAB1216
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