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 Mold/Pollens  Animals Colds  Dust  Exercise  Smoke  Weather  Fragrance Green Zone: Doing Well
● Breathing is good ● No cough wheeze ● Can work and play ● Sleeps all night ● No early warning signs ● Peak Flow Meter if used: 80-100% of personal best _________ School Action: Follow actions in marked boxes below for exercise induced asthma Medication with spacer:  Albuterol  Ventolin  Proventil  Xopenex Medication without spacer:  Maxair Autohaler Dose: __ puffs When: 10-15 minutes before listed activity Start Date: School Year ___ Stop Date: School Year ___ Yellow Zone: Getting Worse
● Cough, wheeze, chest tight ● Problems working/playing ● Early warning signs ● Shortness of breath ● Peak Flow Meter if used: 50 to 80% of personal best _________________ School Actions: Follow actions in marked boxes below
Take Quick-Relief Medication
How Much (Dose)
Start Date
Stop Date
MDI with Spacer:
 Albuterol  Ventolin  Proventil  Xopenex Without spacer:  Maxair Autohaler
Nebulizer:
 Albuterol  Ventolin  Proventil  Xopenex
 If symptoms improve after 10-15 minutes: Return to normal activity
 If symptoms do not improve after 10-15 minutes: Give quick relief medication again and call parents
 If symptoms improve after the second 10-15 minutes: Return to normal activity and call parents
 If symptoms do not improve after the medication is repeated: Call EMS (911), School RN and parents
 If symptoms get worse at anytime: Call EMS (911), School RN and parents
 Report frequent use of quick relief medications (twice a day for 3 days, not for exercise) to the School RN and parents
Red Zone:
● Cannot stop coughing ● Breathing fast ● Flaring nostrils ● Medication not helping Medical Alert
● Getting worse, instead of better ● Trouble walking or talking from shortness of breath ● The skin between the ribs and above the collarbone pulls in or retracts School Actions:
1. Call EMS (911) IMMEDIATELY
2. GIVE QUICK-RELIEVER MEDICATION AND CONTINUE EVERY 15 MINUTES UNTIL EMS (911) ARRIVES
3. Call School RN and Parents
Take Quick-Relief Medication
How Much (Dose)
Start Date
Stop Date
MDI with Spacer:
 Albuterol  Ventolin  Proventil  Xopenex Without spacer:  Maxair Autohaler

Nebulizer:
 Albuterol  Ventolin  Proventil  Xopenex Health Care Provider Name:
Health Care Provider Sign:
NEOLA 2005

Student Name: ____________________________________ Birth Date: ________________________
Address: _________________________________________
School Asthma Action Plan (page 2)
Metered Dose Inhaler (MDI) Instructions
2. Shake the MDI for 5 seconds before each use. 3. Prime the MDI before the first use or when not used every day. Follow the product's patient information sheet for MDI specific priming instructions. Priming usually involves pressing down on the medication canister to discard into the air one or more puff of medication. Discarding puffs makes sure the next puff inhaled contains the labeled amount of medication. 4. Keep track of metered inhalation puffs used. Subtract the number used from the number of metered inhalation puffs available listed on the label. The number of metered inhaled puffs available is listed on the medication canister or on the box. There are usually 200 puffs in an MDI. 5. Ask family for a new MDI when all labeled metered inhalation puffs are used.
MDI and Aerosol Solution Potential Adverse Reaction: Headache, shakiness, fast heart rate, nausea.
Call parent with 1) student report of symptoms that interfere with schoolwork or activity 2) increase in side effects
3) frequent usage (2 times a day for 3 days).
We have instructed the patient and family in the proper use of the quick-relief medications. It is my
professional opinion that the student:
_____ should be allowed to carry and self administer the inhaled medication.
_____ should not carry and self administer the inhaled medication. The medication should be stored
and administered by designated school personnel.
___________________________________________
*********************************************************************************************************************
Section II To Be Completed by Parent
I give permission for my child to receive medication at school in keeping with Section I above according to the
School District policy and as instructed by the physician and agree to 1) Assume responsibility for safe delivery of
the medication in its original container to the school, 2) Have a new form completed by the doctor if medication or
dosage is changed, 3) Notify the school of changes in health care provider. I release from liability, and in addition
agree to indemnify, all school employees, the Board of Education and Akron Children's Hospital School Health
Services for damages or injury resulting from the use, misuse or nonuse of such medication except as such Board,
School Health Service or its employees are grossly negligent or engage in wanton or reckless misconduct. I
further agree to submit a revised statement signed by the Physician who has prescribed the medication described
in Section I in the event that I become aware that any of the above information has changed. I have read and
understand the policy of the School Board for administration of medication and affirm that this request entails
special circumstances justifying an exception from the usual administration of medication at school-by-school
personnel.
Parent/Guardian Signature: ________________________________________ Date: ______________
Daytime Phone: _________________________________________
THIS FORM EXPIRES AT THE END OF THE SCHOOL YEAR
9/1/01
10/1/13

Source: http://www.neola.com/woodridge-oh/search/forms/fm5330F3.pdf

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