STOCK ALBUTEROL DOCUMENTATION LOG
School District
*
School Name
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Male
Female
Other
Gender
*
What is the individual's race?
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
White
Other
If other, please specify
Has this child used the stock inhaler previously?
*
Yes
No
Not Sure
Did the individual have a known asthma diagnosis before this day?
*
Yes
No
Not Sure
Trained School Personnel’s Name
*
Trained School Personnel’s Email
*
example@example.com
Location where symptoms developed
*
Number of albuterol puffs
*
Time of day albuterol was administered:
*
Disposition Status:
*
Called 9-1-1 and transported via EMS
Called 9-1-1 and NO EMS transport
Sent home with parent / guardian / caregiver
Returned to class
EMS Agency Name (If Applicable)
Time EMS called (If Applicable)
Time EMS arrived (If Applicable)
Name of Hospital individual was transported to (If Applicable)
Standing order authority (Physician’s Name)
Comments
Submit
Should be Empty: