Does this child have asthma

Jefferson County Public Schools Health Services
Primary Care Provider Authorization (PCP): Asthma/Allergy (Side One)
2012-2013 School Year
Student Name: ______________________________ Date of Birth: _____________ School: _____________________________
Does this child have ALLERGIC REACTIONS? __ YES __ NO
Does this child have ASTHMA? ____ YES ____ NO
hat things cause this student’s allergic reaction?
__ Medications _____________________
What things may bring on this child’s asthma?
__ Stinging Insects __________________
__ Pollens __ Dust __ Animals __ Exercise __ Foods
__ Other ___________________________
__ Illness __ Other_________________________________
FOOD ALLERGY? __ YES __ NO
Asthma SYMPTOMS may include: Coughing, Shortness of Breath,
Please list any food allergies: _________________________________________
and Wheezing. Please list any other symptoms specific for this child:
Any food not to be served to student: __________________________________
_________________________________________________
Is student Lactose Intolerant? __ YES __ NO
*Please refer to Emergency Plan of Action on Side Two for symptoms

Nutritional info available at
indicating an emergency asthma situation.
you may call 485-
3186 for more information.
Asthma Medications AT SCHOOL:
Order will be for current school year unless otherwise indicated.
SYMPTOMS of the allergic reaction for this child:
__Itching/Swelling of Lips, Mouth, Tongue or Throat
__ Albuterol (Ventolin, Proventil, ProAir, etc)
__Hives/Rash __Nausea/Vomiting/Stomach Cramps
__ 2 puffs every 4-6 hours as needed
__Shortness of Breath __Wheezing __Coughing
__ 2 puffs ___ minutes prior to exercise
__Dizziness __Unconsciousness __ Other __________________________
__ Other____________________________________
Medications AT SCHOOL:
__ Other medication ________________________________
Order will be for current school year unless otherwise indicated.
Instructions ___________________________________
__ EpiPen Jr. __ EpiPen __ Twinject
*If student needs inhaler more than twice a week, please notify parent.
___ Give Epipen/Twinject at onset of allergic reaction and/or exposure to
allergy trigger.
Is this student trained and capable of carrying their own inhaler and
___ Other instructions__________________________________________
using it on their own? ___ YES ___ NO
***IF 2nd DOSE OF TWINJECT OR 2nd EPIPEN NEEDED, give:
If student not carrying inhaler, it is to be kept:
____ Minutes after 1st Dose
__ In front office or student classroom
__ Other _________________________________________
Other medications: _____________________________________________
May student carry own EpiPen/Twinject and use on their own?
__ YES __ NO
If student not carrying EpiPen/Twinject, it is to be kept:
__ In front office or student classroom __Other ______________

Initials/Date Reviewed by Health Services ___________ Entered by Health Services ___________ School received/sent to Health Services ___________ Jefferson County Public Schools Health Services
Primary Care Provider Authorization (PCP): Asthma/Allergy (Side Two)
2012-2013 School Year
Student Name: ______________________________ Date of Birth: _____________ School: _____________________________
EMERGENCY PLAN OF ACTION
1. Follow orders on page 1 for Asthma and/or Allergy treatments and medications.
2. If student is hunched over and/or having dif iculty breathing, walking or talking, blue fingernails or lips, peak flow meter reading in red zone and/or medications not helping, cal EMS
3. Notify school personnel trained in CPR/first aid to respond and initiate CPR if needed prior to EMS arrival.
4. Notify parent/guardian.
5. If EMS is called, the student must be transported via EMS to emergency facility, or parent/guardian must sign release with EMS and then parent/guardian assumes responsibility for
student. The student may not return to school that day. When student is transported via EMS, JCPS staf must ride with student unless parent and/or emergency contact
accompanies them.
6. If student requires medical treatment while on the bus, the bus driver wil contact EMS.
7. Other: ____________________________________________________________________________________________________________________________________________________
FORM MUST BE SIGNED BY HEALTH CARE PROVIDER AND PARENT/GUARDIAN
_______________________________ _______________________________ _________________________________ Printed Name of MD, APRN, or PA ___________________________ _________________________________ Parent/guardian hereby acknowledges that if this medication is not self-administered, it will most likely be administered by trained, unlicensed JCPS personnel. I
acknowledge and agree when I authorize my child to attend a school sponsored field trip, this medication and/or health service may also be administered by a licensed
volunteer. By signing this form, the parent/guardian shall acknowledge that the Jefferson County Board of Education and its employees shall incur no liability as a result
of any injury sustained by the student from the self-administration of his/her medications to treat asthma or anaphylaxis and the parent/guardian shall indemnify and
hold harmless the school and its employees against any claims relating to self-administration of school medication. This form shall not relieve the liability of the school
or its employees for their own negligence. I hereby give permission for the health care provider completing and signing this form to verify this information with JCPS
and consult with JCPS staff regarding this information.
**Parent/Guardian signature required only for INITIAL 2012-2013 PCP form. Parent/Guardian signature not required for updated 2012-2013 PCP form.
____________________________________ __________________________ PLEASE RETURN THIS COMPLETED FORM TO:
Jefferson County Public Schools - Health Services Department
Lam Building, 4309 Bishop Lane, Louisville, KY 40218 Telephone No. (502) 485-3387 Fax: (502) 485-3670
DRAFT 5/22/12

Source: http://www.strathmoorpediatrics.com/wp-content/uploads/2012/12/jcps-asthma-allergy-form.pdf