Beaufort-Jasper Eoc Head Start

Seizure Action Plan

Child's Last Name:*
Child's Middle Name:
Child's First Name:*
What program option are you registering for?*

Center:*
Date of Birth:*
Teacher:
Physician’s Phone:

Emergency Contacts
Name:*
Relationship:
Home Phone #:
Work Phone #:
Cell Phone #:

Name:
Relationship:
Home Phone #:
Work Phone #:
Cell Phone #:

Name:
Relationship:
Home Phone #:
Work Phone #:
Cell Phone #:

Type of seizure:
What does the seizure look like and how long does it usually last?
Possible triggers that should be avoided:

Does child need any special activity adaptations/protective equipment (e.g., helmet) at school?
If Yes, Explain

Is child allowed to participate in physical education and other activities?*
If Yes, Explain

Are Medications Needed To Control The Seizures?*
If Yes, List below the medications needed
Medications* Amount Taken How Often And For What Signs
List medication needed at the center (name, dosage/route, and frequency)
Possible side effects that must be reported to parent or physician:

If Generalized Seizure Occurs:
1. Call 911. Contact Center Manager or Ms. Daniels, the child’s parent.
2. If falling, assist child to floor, turn to side.
3. Loosen clothing at neck and waist; protect head from injury.
4. Clear away furniture and other objects from area.
5. Have another classroom adult direct children away from area.
6. Time The Seizure.
7. Allow seizure to run its course; DO NOT restrain or insert anything into the child’s mouth. Do not try to stop purposeless behavior.
8. During a general or grand mal seizure expect to see pale or bluish discoloration of the skin or lips. Expect to hear noisy breathing.

If Smaller Seizure Occurs(e.g., lip smacking, behavior outburst, staring, twitching of mouth or hands)
1. Call 911. Contact Ms. Daniels or Nurse Hatchett, the child’s parent and 911
2. If falling, assist child to floor, turn to side.
3. Assist child to comfortable, sitting position.
4. Time the seizure.
5. Stay with child, speak gently, and help student get back on task following seizure.

If Child Exhibits:
1. Absence of breathing or pulse CALL911.
2. Seizure of 10 minutes or greater duration.
3. Two or more consecutive (without a period of consciousness between) seizures which total 10 minutes or greater.
4. Continued unusually pale or bluish skin or lips or noisy breathing after the seizure has stopped.

Intervention:
1. Call 911, the parent, Ms. Daniels or Nurse Hatchett
2. START CPR for absent breathing or pulse.

When Seizure Completed:
1. Reorient and assure child.
a. Assist change into clean clothing if necessary.
b. Allow child to sleep, as desired, after seizure.
c. Allow child to eat, as desired, once fully alert and oriented.
2. A child recovering from a generalized seizure may manifest abnormal behavior such as incoherent speech, extreme restlessness, and confusion. This may last from five minutes to hours.
3. Inform parent immediately of seizure via telephone conversation if:
a. Seizure is different from usual type or frequency or has not occurred at school in past month.
b. Child has not returned to "normal self" after 30-60 minutes.
4. Record seizure on Seizure Activity Log.


Emergency Bus Plan
Driver/attendant Information Sheet
Child's Last Name:*
Child's Middle Name:
Child's First Name:*
Center:
Teacher:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Parent/Guardian:*
Am Route:
Pm Route:
Home Phone #:
Work Phone #:
Cell Phone #:

Emergency Contact:
Phone:
Other Phone:

Physician:
Physician Tel:
Physician Fax:

Special Equipment Or Medical Needs On Bus
I.E. OXYGEN TANK, WHEELCHAIR, SEIZURES, GO-BAGS, ETC.- PLEASE INCLUDE SIZE AND DIMENSIONS OF ALL EQUIPMENT

I want this plan implemented for my child, , at Beaufort Jasper EOC Head Start. Medication will be furnished by parent/guardian in a container properly labeled by a pharmacist and in the original container. All medications must have child's name, medication dispensed, dose prescribed and time it is to be given. I hereby give my permission for my child to receive medication during school hours. This medication has been prescribed by a licensed physician. I hereby release Beaufort Jasper EOC Head Start and their staff from all liability that may result from my child taking the prescribed medication. I give permission for the Beaufort Jasper Head Start Staff to communicate with the Medical Provider concerning diagnosed medical condition related to above prescribed medication.
I confirm that I have read and understand this form. *

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Parent Signature
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