Accucare Staffing Form
Complete this form to provide essential information for safe and effective student transport via school bus.
Patient Name
*
Gender
*
Male
Female
Primary Language
*
Nurse Name
*
School
*
AM Pickup Location/Time
PM Drop-off Location/Time
Bus Company
Bus Type
General Population
Special Needs
Bus Aide Present
Yes
No
Bus Number
Primary Diagnosis
Critical Risks
Seizure
Aspiration
Respiratory
Behavioral
Cardiac
Other
Critical Risks - Other
Allergies
Level of Consciousness
Communication
Mobility
Ambulatory
Wheelchair
Non-ambulatory
Oxygen
Yes
No
Oxygen Flow (L/min)
Suction
Yes
No
Seizure History
Yes
No
Seizure Type(s)
Tonic-Clonic
Absence
Focal
Atonic
Myoclonic
Other
Seizure Type(s) - Other
Typical Presentation
Emergency Medication (Seizure)
Seizure Plan - When to Intervene
Seizure Plan - Actions to Take
Seizure Plan - Call 911 If
Anaphylaxis History
Yes
No
Known Triggers
Epinephrine Available
Yes
No
Epinephrine Location
Anaphylaxis Plan - When to Intervene
Anaphylaxis Plan - Actions to Take
Anaphylaxis Plan - Call 911 If
Other Emergency Condition
Other Emergency Plan - When to Intervene
Other Emergency Plan - Actions to Take
Other Emergency Plan - Call 911 If
Controlled Medication Sheet
Yes
No
Pre-Transport Safety Check
Patient stable
Airway clear
Equipment secured
Emergency meds present
Seatbelt/wheelchair secured
Nurse Responsibilities
Continuous supervision
Maintain airway & positioning
Monitor for seizures/respiratory distress
Maintain precautions
Ensure equipment functioning
Other
Positioning
Transfer Instructions
Assist level required
Independent
1-person assist
2-person assist
Mechanical lift
Safety Precautions
Patient may ONLY be released to
Parent/Legal Guardian
Designated Caregiver
School Nurse
Parent/Caregiver
Supervisor
Save and Continue
Submit
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