Otsego Elementary School Faculty Handbook - Half Hollow Hills

EMERGENCY HEALTH PLAN CARE FORM
Half Hollow Hills
Central School District
Emergency Health Care Plan
(To be completed annually by Parent and Child’s Physician)
Attach
Child’s
Photo
Student Name:
Date of Birth:
Teacher:
School Year:
Allergy:
Reacts to: Ingestion ________ Airborne ________ Tactile________
SIGNS OF AN ALLERGIC REACTION INCLUDE:
Systems:
Symptoms:
Mouth Itching and swelling of the lips, tongue, or mouth
Throat Itching and/or a sense of tightness in the throat, hoarseness, hacking cough
Skin Hives, itchy rash, and/or swelling about the face or extremities
Gut Nausea, abdominal cramps, vomiting, and/or diarrhea
Lung Shortness of breath, repetitive coughing
Heart “thready” pulse, “passing out”
ACTION: MILD ALLERGIC SYMPTOMS
1. Administer: ___________________________________________________
medication/dosage/route/frequency
2.
Call Parents: ______________________________________________________
Mother’s work # home # cell#
______________________________________________________
Father’s work # home # cell#
ACTION: SEVERE ALLERGIC SYMPTOMS (ANAPHYLAXIS)
1. Administer: ___________________________________________________
medication/dosage/route/frequency
2. Call Rescue: Melville Fire Department 631-547-4121
Call Parents: ______________________________________________________
3.
Mother’s work # home # cell#
______________________________________________________
Father’s work # home # cell#
Do not hesitate to administer medication or call rescue squad, even if parents or doctor
cannot be reached!
_____________________________________________
Parent’s Signature
_____________________________________________
Physician’s Signature
_________________
Date
_________________
Date
Please note that medication must be transported to and from the health office by a parent
or guardian. Medication must be labeled and in the original container.