INDIVIDUALIZED PLAN FOR A CHILD WITH MEDICAL NEEDS

INDIVIDUALIZED PLAN FOR A CHILD WITH MEDICAL NEEDS

This form must be completed for a child who has one or more acute * or chronic ** medical conditions such that he or she requires additional supports, accommodation or assistance.
Special Instructions:
- *Acute: a condition that is severe and sudden in onset that, if left untreated, could lead to a chronic syndrome.
- **Chronic: a long-developing syndrome that can develop or worsen over an extended period of time.
- Each child with medical needs requires their own individualized plan. If significant changes and updates are required to this individualized plan, a new individualized plan must be completed.
- An additional individualized plan is not required for a child with an anaphylactic allergy, if the child does not otherwise have a medical need, as these children must already have an individualized plan under the anaphylactic policy.
- Children's personal health information should be kept confidential.
Photo of Child (recommended)
Child's Full Name
Child's Date of Birth

MonthDayYear
Date
Date Individualized Plan Completed:

MonthDayYear
Date
Medical Condition(s):

DiabetesAsthmaSeizureOther
Prevention and Support
STEPS TO REDUCE THE RISK OF CAUSING OR WORSENING THE MEDICAL CONDITION(S):
[Include how to prevent an allergic reaction/other medical emergency; how not to aggravate the medical condition (e.g. Pureeing food to minimize choking)]
LIST OF MEDICAL DEVICES AND HOW TO USE THEM (if applicable):
(e.g. feeding tube, stoma, glucose monitor, etc.; or not applicable (N/A))
LOCATION OF MEDICATION AND/OR MEDICAL DEVICE(S) (if applicable):
(e.g. glucose monitor is stored on the second shelf in the program room storage closet; or not applicable (N/A))
SUPPORTS AVAILABLE TO THE CHILD (if applicable):
(e.g. nurse or trained staff to assist with feeding and/or disposing and changing of stoma bag; or not applicable (N/A))
SUPPORTS AVAILABLE TO THE CHILD (if applicable):
(e.g. nurse or trained staff to assist with feeding and/or disposing and changing of stoma bag; or not applicable (N/A))
Symptoms and Emergency Procedures
SIGNS AND SYMPTOMS OF AN ALLERGIC REACTION OR OTHER MEDICAL EMERGENCY:
[include observable physical reactions that indicate the child may need support or assistance (e.g. hives, shortness of breath, bleeding, foaming at the mouth)]
PROCEDURE TO FOLLOW IF CHILD HAS AN ALLERGIC REACTION OR OTHER MEDICAL EMERGENCY:
[Include steps (e.g. Administer 2 puffs of corticosteroids; wait and observe the child's condition; contact emergency services/parent or guardian, parent/guardian/emergency contact information; etc]
PROCEDURES TO FOLLOW DURING AN EVACUATION:
(e.g. ice packs for medication and items that require refrigeration; how to assist the child to evacuate)
PROCEDURES TO FOLLOW DURING FIELD TRIPS:
(e.g. how to plan for off-site excursion; how to assist and care for the child during a field trip)
Additional Information Related to the Medical Condition (if applicable):
This plan has been created in consultation with the child's parent / guardian.
This plan has been created in consultation with the child's parent / guardian.
Print name
Relationship to child
Signature

Clear
Date dd/mm/yyyy

MonthDayYear
Date
The following individuals participated in the development of this individual plan (optional):
First and Last Name
Position/Role
Parent's email:
example@example.com
Signature

Clear
Frequency at which this individualized plan will be reviewed with the child's parent/guardian:
Should be Empty:

INDIVIDUALIZED PLAN FOR A CHILD WITH MEDICAL NEEDS

Prevention and Support

Symptoms and Emergency Procedures