Asthma Action Plan (AAP)

Asthma Action Plan (AAP)
Student Name*
Date of Birth*

MonthDayYear
Date
Grade
School Name
Parent Name*
Parent Phone Number*
Parent Email*
example@example.com
Physician
Physician Phone Number
Physician Fax or email
example@example.com
School Nurse
School Phone Number
School Fax or email
example@example.com
Severity Classification*

IntermittentMild PersistentModerate PersistentSevere Persistent
Triggers*

IllnessExerciseAnimalsSmokeDustFoodWeatherAir QualityPollenOther (specify)
Air Quality: Student should stay indoors when Air Quality Index is

ModerateUnhealthy for sensitive groupsUnhealthyOther
When does student use the inhaler?*

Before exercise/exposure to a triggerOther (specify)
Controller medication student takes every day at home
How Much?
ie. 1 puff, 2 puffs...
How Often?
ie. 4-6 hours, twice a day
Quick-Relief Medication student uses with flare ups*
How Much?*
ie. 1 puff, 2 puffs...
How Often?*
ie. 4-6 hours
Select ALL that apply*

Student is independent using inhalerStudent needs supervision when using inhalerStudent needs assistance with inhalerStudent uses a NebulizerStudent uses an Inhaler with spacerStudent uses an Inhaler
Parental Responsibilities:
- The parent or guardian is to furnish the asthma medication and bring tot the school in the current original pharmacy container and pharmacy label with the child’s name, medication name, administration time, medication dosage, and healthcare provider’s name.
- The parent or guardian, or other designated adult will deliver to the school and replace the asthma medication when empty.
- If a student has a change in theirprescription, the parent or guardian is responsible for providing the newly prescribed information and dose information as described above to the school. The parent or guardian will complete an updated Asthma Action Plan before designated staff can administer the updated asthma medication prescription.
Parent/Guardian Authorization*

I authorize my child to carry and self administer the prescribed medication described above. My student is responsible for, and capable of, possessing or possessing and self administering an asthma inhaler per UCA 53G-9-503. My child and I understand there are serious consequences for sharing any medication with others.I do not authorize my child to carry and self administer this medication. Please have the appropriate/designated school personnel maintain my child’s medication for use in an emergency.I authorize the appropriate/designated school personnel maintain my child’s medication for use in emergency.
Parent Signature*

Clear
Date

MonthDayYear
Date
As parent/guardian of the above named student, I give my permission to the school nurse and other designated staff to administer medication and follow protocol as identified in the asthma action plan. I agree to release, indemnify, and hld harmless the above from lawsuits, claim expense, demand or action, etc.,against them for helping this student with asthma treatment, provided the personnel are following prescriberinstruction as written in the asthma action plan above. Parent/Guardians and students are responsible for maintaining necessary supplies, medication and equipment. I give permission for communication between the prescribing health care provider, the school nurse, the school medical advisor and schoolbased clinic providers necessary for asthma management and administration of medication. I understand that the information contained in this plan will be shared with school staff on a needtoknow basis and that it is the responsibility of the parent/guardian to notify school staff whenever there is any change in the student’s health status or care.
Parent Name*
Parent Signature*

Clear
Date

MonthDayYear
Date
Emergency Contact Name*
Relationship*
Phone*
Should be Empty:

Asthma Action Plan (AAP)

Parental Responsibilities: