ALLERGY PREVENTION AND RESPONSE MANUAL · The best form of prevention for life-threatening allergic...

““““N ational D istrict of CharacterN ational D istrict of CharacterN ational D istrict of CharacterN ational D istrict of Character

ALLERGY

PREVENTION

AND

RESPONSE

MANUAL

745 Jeffco Blvd. Arnold, MO 63010 p 636.296.8000 f 636.282.5170 www.fox.k12.mo.us

STUDENTS Policy 2825

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Student Services

Allergy Prevention and Response

The purpose of this policy is to create an organizational system for preventing and responding to

allergic reactions. This policy is not a guarantee of an allergen-free environment; instead, it is

designed to increase awareness, provide education and training, reduce the chance of exposure

and outline responses to allergic reactions. The best form of prevention for life-threatening

allergic reactions is avoidance of the allergen.

Research shows that allergies can negatively impact student achievement by affecting

concentration, learning and attendance. Healthy students are better learners. In addition to

posing health risks, allergies can be potentially deadly for some individuals.

This policy applies to district facilities to which students have access and includes transportation

provided by the district. The superintendant or designee, in cooperation with other pertinent staff

members, has developed the following procedures to implement this policy.

Allergy Prevention and Response Procedures

The superintendant or designee shall oversee the implementation of these procedures in

consultation with the director of nursing, director of food service, director of transportation,

health and wellness committee, and when appropriate the director of special education or 504

coordinator.

Identification:

Each school will attempt to identify students with potentially life threatening allergies through at

least an annual review of all individual student Health Inventory Forms. The nurse at this time

will refer students for 504 and/or IDEA eligibility when appropriate.

Prevention:

An Emergency Action Plan and/or Individualized Healthcare Plan may be developed for students

with a diagnosed potentially life threatening allergy. This will be provided to, and reviewed

with, staff members who need to know this information in order to provide a safe environment

for the student. Appropriate staff members will be determined by the principal and school nurse.

Education and Training:

All certified and noncertificated staff members will be trained by a school nurse or by viewing a

district approved health education resource video on the causes and symptoms of, and responses

to, allergic reactions. Training will include instruction on the use of epinephrine pre-measured

auto injection devices.

Age appropriate education on allergies and allergic reactions will be provided to students by a

trained staff member or by viewing a district approved health education resource video.

Education will include potential causes, information on avoiding allergens, signs and symptoms

of allergic reactions and simple steps students can take to keep classmates safe.

Policy 2825

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Confidentiality:

Information about individual students with allergies will be provided to all staff members who

need to know the information in order to maintain a safe environment for the student, as

permitted on the Health Inventory Form. Appropriate staff members will be determined by the

principal and school nurse.

Responses:

Responses to allergic reactions will be in accordance with established procedures. It is the

responsibility of the parents to provide their child’s school with the necessary paperwork and

medication needed to carry out the student’s plan of action in case of exposure. Each building

will maintain an adequate supply of epinephrine premeasured auto-injection devices to be

administered according to the Anaphylaxis Protocol adopted by the district. Appropriate staff

members, as determined by the principal and nurse, will be notified about students with

potentially life threatening allergies as well as plans of action in case of exposure.

Plans and Protocols:

Students with allergies may rise to a level that requires special plans/protocols to be initiated.

These plans/protocols can include one or more of the following depending on the type and status

of the allergy:

Emergency Action Plan is a written plan completed/signed by parents and physician for students

who have life-threatening conditions, such as an allergy. This plan is designed to inform school

district personnel who may be called upon to respond.

Individualized Healthcare Plan is a document created by the nurse in cooperation with the staff,

parents and the student’s health care provider, when appropriate. It is for students who have

specific health care needs. It is a nursing care plan that has student-centered goals and

objectives, and describes the nursing interventions designed to meet the student’s short and long-

term goals.

Anaphylaxis Emergency Protocol is the district adopted procedure to follow in case of a life

threatening reaction to an allergen for students with no Emergency Action Plan in place. This

requires allergy and epinephrine premeasured auto-injection device training in order to initiate.

Food Allergy Awareness Protocol is the district adopted procedure to follow for students who

have a potentially life threatening allergy to food and is completed/signed by parents and

physician. It is always initiated when a student provides the district with an epinephrine

premeasured auto-injection device to be used in cases of exposure to an allergen resulting in a

potentially life threatening reaction.

Individual 504 Non-Discrimination Plan is the procedure to follow for students who are eligible

due to a mental or physical impairment that substantially limits one or more of their major life

activities. This plan is created by a multidisciplinary team and will allow the student to be

educated in the regular classroom setting to their fullest extent.

Individual Education Plan is the procedure to follow for students with identified disabilities. It

provides the assistance they need to learn and progress in their schoolwork successfully. This

plan is created by a multidisciplinary team in order to determine the special education services

and supports that the student needs in order to achieve at their highest potential.

Policy 2825

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The above plans and protocols will be reviewed and updated at least annually by the appropriate

members of the multidisciplinary team.

Food Allergy:

Food allergy is a growing concern and creates a significant challenge for children in school.

Increasing numbers of children are diagnosed with a potentially life-threatening condition known

as anaphylaxis. The only way to prevent this from occurring is avoidance of the identified food

allergen. Critical to saving lives are plans that include life-threatening food allergy education

and awareness, avoidance of allergens, and treatment of anaphylaxis. Ingestion of the food

allergen is the principal route of exposure leading to an allergic reaction ranging from mild skin

reactions to life-threatening reactions. The top eight most common food allergens are milk,

eggs, peanuts, tree nuts, shellfish, fish, wheat and soy. The most prevalent food allergens for

children are milk, eggs and peanuts. For students with potentially life threatening food allergies

their plan of action will be followed. The district’s Food Allergy Awareness Protocol will always

be initiated when a student provides the district with an epinephrine premeasured auto-injection

device to be used as a result of exposure to an allergen causing a potentially life threatening

reaction.

Insect Allergy:

Stinging insects commonly include bees, wasps, hornets, yellow jackets, paper wasps and fire

ants. For most, complications include pain and redness at the bite site. However, some people

can have a potentially life threatening response. In these cases treatment is needed following the

student’s plan of action.

Latex Allergy:

Latex products such as balloons, gloves, and gym equipment are a common cause of allergic

type reactions. Two common types of reactions include contact dermatitis and immediate

allergic reactions. Contact dermatitis, a type of localized allergic reaction to skin, can occur on

any part of the body that has contact with latex products, usually after 12-36 hours. Immediate

allergic reactions, however, are potentially the most severe form of allergic reaction to latex.

Exposure can lead to anaphylaxis depending on the amount of allergen exposure and the degree

of sensitivity. Latex should be avoided by students and staff at risk for anaphylaxis, however, a

latex free environment cannot be guaranteed. Latex free supplies and equipment should be used

when available. Proper signage will be posted and letters sent home when necessary. In cases

when a reaction occurs as a result of exposure the student’s plan of action should be initiated.

Medication:

Any medication which a student is allergic to as noted on the Health Inventory Form will not be

administered. In cases when accidental exposure occurs causing a severe reaction the district’s

Anaphylaxis Emergency Protocol should be initiated.

Resources:

It is important to use appropriate resources when obtaining information needed to make informed

decisions.

Conclusion:

Life threatening allergies can result in anaphylaxis, which requires a medical response.

Epinephrine is the treatment of choice for anaphylaxis and should be administered as soon as

Policy 2825

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possible. However, prevention is the most important method in the management of allergic

reactions. Avoidance of exposure to the allergen is the best way to prevent a reaction. With

procedure in place and proper training, allergic reactions can be dealt with in a safe and efficient

manner.

*For additional information see the Allergy Prevention and Response Manual located in the

nurse’s office in each building.

Adopted: 5/11 Effective: 5/11, 12/11

Revised: 12/11

Consolidated School District No. 6 (Fox)

FORM A FOX C-6 STUDENT HEALTH INVENTORY

PLEASE USE BLUE OR BLACK INK AND COMPLETE THE OTHER SIDE Name_____________________________________________ Date of Birth_____________________ Sex _________ Grade ____________ Teacher_________________________________ Address ________________________________________City ________________Zip____________ Home Phone ______________________ Cell # ____________________ Bus # _________________ Child lives with: Mother Father Stepmother Stepfather Grandparent(s) Other: ____________________ Mother’s Name: _____________________________ Cell/Pager ______________________________ Employment: ______________________________________ Phone: __________________________ Father’s Name: ______________________________ Cell/Pager ______________________________ Employment: _______________________________________ Phone: _________________________ Since the care and treatment of the student is primarily the responsibility of the parent, every effort will be made to contact the parent first. Please list Other Substitute Contacts who can be contacted regarding student’s care in the event a parent cannot be located. PLEASE NOTE: Only those listed below will be permitted to pick up your child in case of illness or emergency. Name: _________________________________________ Phone: ____________________________ Relation: ______________________________Work #:_____________________________________ Name: _________________________________________ Phone: ____________________________ Relation: ______________________________Work #:_____________________________________ Name: _________________________________________ Phone: ____________________________ Relation: ______________________________Work #:_____________________________________ Name: _________________________________________ Phone: ____________________________ Relation: ______________________________Work #:______________________________________ List anyone who is NOT PERMITTED to visit/pick up your child from school: Are court order custody papers on file in office? Y N Name:________________________________________ Name: _______________________________

AUTHORIZATION FORM Student_________________________________________ School____________________ Grade__________

� I hereby authorize the emergency treatment of anesthesia and surgical treatment for my minor child in the event of an emergency medical situation occurring during my absence or when school hospital/medical authorities are unable to contact me. I release from responsibility and liability, hospital/medical authorities for performing medical procedures deemed necessary during my absence.

� I do not wish my child to receive emergency medical/treatment administered at a hospital/medical center in my

absence Parent/Guardian Signature________________________________________ Date_____________________ Address______________________________________________ Telephone________________ Name of Family Doctor__________________________________________ Telephone_________________

PLEASE COMPLETE HEALTH INFORMATION ON BACK

NAME: __________________________________TEACHER:_______________

HEALTH INFORMATION MEDICATION POLICY : Medication will be given by designated school personnel only on orders of a physician and/or written authorization of a parent or legal guardian. Both prescription and over-the-counter medication must be sent in original containers (box/bottle) with child’s name, room number, time, and amount of medication. Exception for Potentially Harmful Administration: It shall be the policy of this District that the District will not knowingly administer any medication to a student that exceeds the highest recommended dosage listed in the current annual volume of the Physician’s Desk Reference, Clinical Pharmacology, or other recognized medical or pharmaceutical text.

May your CHILD be given TYLENOL? YES____________ NO _________

May your CHILD be given TUMS? YES____________ NO_________ Does your child have: Allergies? Y N To drugs, food, insects, pollen, animals? Please list_______________________________ _______________________________________________________________________ Y N Describe reaction: _____________________________________ ___________________ ________________________________________________________________________ Difficult breathing? Y N Need Emergency medication? Y N

Asthma? Y N Triggered by: ____________________________________________________________ Treatment: ______________________________________________________________ Carries Inhaler? Y N Required paperwork completed? Y N Diagnosed by doctor: _________________________ Date: _______________________ Diabetes? Y N Takes Insulin? Type: ______________________________________________________ Insulin pump: ____________________________________________________________ Epilepsy/Seizures Y N Describe seizure: ________________________________________________________ ______________________________________________________________________ Date of last seizure: __________________Medication: _________________________ Heart condition? Y N Describe: _____________________________________________________________ Restrictions? ___________________________________________________________ Other Concerns? ____________________________________________________________________________ Daily Medication: At home? Y N Medication/Dosage/Time: ________________________________________

Diagnosis: __________________________________________________________________ At School? Y N Medication/Dosage/Time: ________________________________________

Diagnosis: ____________________________________________________________ Glasses/Contacts (circle one if appropriate) Date of last exam: ________________________________________ The above information may be shared with other school personnel on a need to know basis.

Parent Signature: _______________________________________________ Date: ______________________________________________________________________________

Siblings in other Fox Schools: 1. ________________________________________________ 2 _______________________________________________________ 3 _______________________________________________ 4. _______________________________________________________ Previous Fox school attended____________________________________________________________________________________ Last School attended __________________________________________________________________________________________

FORM B FOX C-6 STAFF TRAINING

“ALLERGIES”

DEFINITION:

Allergy is a reaction that the bodies’ immune system produces that is

inappropriate in relation to something that would normally be innocent. The

reaction can be local or general in nature.

TYPES:

People can be allergic to many things. It is important to note that allergies

can develop even after there have been multiple exposures to the allergen.

Some examples are as follows:

1) Airborne such as tree pollens, smoke and mold.

2) Animals such as cats and dogs.

3) Bug bites such as bees, wasps and mosquitoes.

4) Foods such as nuts, milk, seafood, to name a few. An individual

can be allergic to any kind of food.

5) Medications such as antibiotics.

6) Latex such as balloons and gloves.

REACTIONS:

1) Local reactions can include redness, swelling, rash and itching.

Airborne reactions can include watery, swollen and itchy eyes,

throat and nasal congestion, sneezing, coughing and asthmatic

symptoms.

2) General reactions involve the entire body and multiple systems.

This can be a severe and life threatening anaphylactic reaction.

Reactions can include:

a. Generalized itching and tingling

b. Swelling of lips, tongue and periorbital area.

c. Weakness.

d. Rapid pulse.

e. Fall in blood pressure.

f. Respiratory difficulty or distress.

g. Cold, clammy skin.

h. Loss of consciousness

i. Nausea and/or vomiting.

j. Abdominal cramping.

TREATMENT:

1) Local reactions are generally treated with an oral antihistamine

such as Benadryl.

2) General/Anaphylactic reactions are treated with Epinephrine

injections and an oral antihistamine. There are some important

things to remember about Epinephrine:

a. Dose: Epi-pen Junior for those weighing less than 66

pounds. Adult Epi-pen for those weighing more than 66

pounds. Always error on the side off too much verses not

enough. Dose may be repeated in 5 minutes if there is no

relief of symptoms.

b. Side Effects: Increased heart rate, trembling, headache, and

increased blood pressure. Symptoms will wear off in

approximately 15–30 minutes.

c. Duration: Begins acting in seconds and has approximate 15-

20 minute duration of action. Always call 911 when Epi-

pen is given since duration is short and symptoms may

reappear when the med wears off.

3) Always error on the side of giving the Epi-pen. It is better to be

dealing with the side effects of the medication which will wear off

in 15-30 minutes verses the other option!

PREVENTION:

1) Education

2) Avoidance of the allergen

3) Good hand washing

FORM C Allergy Emergency Action Plan Name: ______________________________________________________ Teacher: ______________________

ALLERGY TO : ___________________________________________________________________

Asthmatic Yes* □ No □ *Higher risk for severe reaction

STEP 1: TREATMENT

Symptoms: Give Checked Medication**: **(To be determined by physician authorizing treatment)

If an exposure to the allergen occurs, but no symptoms: □ Epinephrine □ Antihistamine

Mouth Itching, tingling, or swelling of lips, tongue, mouth □ Epinephrine □ Antihistamine

Skin Hives, itchy rash, swelling of the face or extremities □ Epinephrine □ Antihistamine

Gut Nausea, abdominal cramps, vomiting, diarrhea □ Epinephrine □ Antihistamine

Throat† Tightening of throat, hoarseness, hacking cough □ Epinephrine □ Antihistamine

Lung† Shortness of breath, repetitive coughing, wheezing □ Epinephrine □ Antihistamine

Heart† Weak or thready pulse, low blood pressure, fainting, pale, blueness □ Epinephrine □ Antihistamine

Other† ________________________________________________ □ Epinephrine □ Antihistamine

If reaction is progressing (several of the above areas affected), give: □ Epinephrine □ Antihistamine † Potentially life-threatening. The severity of symptoms can quickly change.

DOSAGE Epinephrine: inject intramuscularly (circle one) EpiPen® EpiPen® Jr. Twinject® 0.3 mg Twinject® 0.15 mg (see reverse side for instructions)

Antihistamine: give____________________________________________________________________________________ medication/dose/route

Other: give____________________________________________________________________________________________ medication/dose/route

IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis.

STEP 2: EMERGENCY CALLS

1. Call 911. State that an allergic reaction has been treated, and additional epinephrine may be needed.

2. Dr. ______________________________________Phone Number: _____________________________________________

3. Father___________________________________ Home_______________ Cell_______________ Work_______________

Mother__________________________________ Home_______________ Cell_______________ Work_______________

4. Emergency contacts: Name/Relationship:

a. _____________________________________________Home_______________ Cell_________________ Work________________

b. _________________________________________Home_______________ Cell_______________ Work_______________

EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT H ESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILI TY!

Parent’s Signature______________________________________________________ Date_____________________________

Doctor’s Signature______________________________________________________Date_____________________________

Place Child’s Picture Here

FORM D FOX C-6 SCHOOL DISTRICTINDIVIDUALIZED HEALTHCARE PLAN

STUDENT'S NAME:BIRTHDATE:

CONTACTS:MOTHER'S NAME:ADDRESS:HOME NUMBER:CELL NUMBERWORK NUMBER:

FATHER'S NAME:ADDRESS:HOME NUMBER:CELL NUMBERWORK NUMBER:

PHYSICIAN'S NAME:ADDRESS:NUMBER:

HOSPITAL'S NAME:ADDRESS:NUMBER:

INDIVIDUALIZED HEALTHCARE PLANNURSING ASSESSMENT

MEDICAL HISTORY

NURSING ASSESSMENT

DATE INITIALS NURSING DIAGNOSIS OUTCOME/GOAL PLANNING & IMPLEMENTATION EVALUATIONKNOWLEDGE DEFICIT

___Health or disease process ___Student/Parent will verbalize and/or demonstrate understanding of teaching___Teaching regarding health or ___Student/parent verbalized and/ demonstrate understanding of disease process or demonstrated understanding

___Procedures/Treatments teaching. of health or disease process___Teaching procedures/treatments Date:_____________________

___Self care ___Other___Teaching self care that is age ___Student/parent verbalized and/

___Orientation to environment appropriate or demonstrated understanding of treatments and procedures

___Safety measures ___Teaching medications Date:_____________________

___Other ___Orient student to building ___Student performs self care as age appropriate

___Provide safety measures Date:_____________________

___Other ___Student/parent verbalized and/ or demonstrate understanding of medications Date:_____________________

___Student is familiar with building Date:_____________________

___Student remained safe while in building Date:_____________________

___Other Date:_____________________

NURSES NOTES

DATE INITIALS NURSING DIAGNOSIS OUTCOME/GOAL PLANNING & IMPLEMENTATION EVALUATIONALTERATION IN

HEMODYNAMIC STATUS

___Fluid volume disturbance ___Student will have a record of vital ___Monitor and chart vital signs and ___Nurse maintained necessary signs taken when needed weight as ordered paperwork/documentation

___Arrhythmias Date:________________________Student will have received prompt ___Provide prompt treatment of

___Abnormal blood pressure treatment for bleeding issues bleeding issues. ___Nurse provided prompt treatment of bleeding issues

___Low cardiac output ___Student will exhibit a minimal ___Use universal precautions when Date:_____________________ amount of disruption in activities handling blood products

___Hemorrhagic disorder of daily living ___Student had minimal disruption___Make staff aware of student's of daily activities

___Anemia ___Emergency services will be issues and how to handle blood Date:_____________________ initiated when necessary spills

___Altered renal function ___Emergency services were___Parents will be kept informed of ___Administer medication prescribed initiated when needed

___Edema student's status while at school Date:________________________Keep parents informed of school

___Dehydration ___Other issues as they occur ___Universal precautions were observed

___Other ___Other Date:_____________________

___Parents were kept informed of student's status at school Date:_____________________

___Other Date:_____________________

NURSES NOTES


RESPIRATORY STATUS

___Impaired gas exchange Student will maintain clear, open ___Assess student with complaints ___Student was assessed whenairways as evidenced by: of respiratory difficulty/911 prn verbalized respiratory complaint

___Ineffective breathing Date:________________________Clear breath sounds ___Listen to breath sounds

___Ineffective airway clearance ___Vital sign were monitored___Normal rate and depth of ___Monitor respiratory and apical Date:_____________________

___Other respiration pulse rate___Pulse ox level was obtained

___Absence of cyanosis ___Observe for signs of cyanosis of Date:_____________________ lips and nail beds

___Pulse ox within normal limits ___Student was suctioned as___Monitor pulse ox level needed

___No evidence of intercostal Date:_____________________ retraction ___Observe for intercostal retraction

___Medications were administered___Normal heart rate ___Suction student as needed as prescribed by physician

Date:________________________Other ___Administer medications

___Emergency services were___Other activated

Date:_____________________

___Treatment was prompt in order to minimize compromise Date:_____________________

___Other Date:_____________________

NURSES NOTES


NUTRITIONAL STATUS

___Food Allergy ___Student will maintain or improve ___Environment conducive to eating ___Student maintained or im- nutritional status at school proved nutritional status while

___Food intolerance ___Assist with feeding at school___Student will be free of aspiration Date:_____________________

___Nausea/emesis/diarrhea ___Flow sheets as necessary___Student will tolerate nutritional ___Student remained free of

___Risk of aspiration intake ___Monitor weight as needed aspiration Date:_____________________

___Tube feeding ___Student will avoid food allergens ___Personal assistive devices as needed ___Student tolerated nutritional

___Diabetes mellitus ___Staff will be educated regarding intake food allergen ___Referral to lactation service Date:_____________________

___Weight loss/gain > 10#___Other ___Educate staff on food allergen ___Student avoided food allergen

___Pregnant/lactating Date:________________________Medical statement for students

___Inability to chew/swallow requiring special meals form ___Staff educated regarding food allergen

___Other ___Other Date:_____________________

___Other Date:_____________________

NURSES NOTES


PSYCHO/SOCIAL STATUS

___Anxiety ___Student will verbalize/demonstrate ___Provide student with reassurance ___Student verbalized/demon- reduction in anxiety stated reduction in anxiety

___Body image disturbance ___Talk openly to student about Date:________________________Student responds and verbalizes body image disturbance

___Denial appropriately to situations ___Student responded and ___Confront student in area of denial verbalized appropriately to

___Noncompliance ___Other situations___Confront student regarding non- Date:_____________________

___Not feeling accepted compliance___Other

___Other ___Exhibit acceptance of student Date:_____________________

___Other

NURSES NOTES


AUTOIMMUNE STATUS

___Allergies ___Student will have minimal allergic ___Avoid contact with allergen ___Student avoided contact with ___Food__________________ reactions while at school allergen____________________________ ___Educate student regarding aller- Date:_____________________

___Student will verbalize understand- gies/symptoms/treatment ___Insects________________ ing of allergies/symptoms/treat- ___Student was educated regard-____________________________ ment ___Educate staff regarding allergies/ ing allergies/symptoms/treat-

symptoms/treatment ment ___Medication_____________ ___Staff will be educated on allergies/ Date:_________________________________________________ symptoms/treatment ___Assess student for symptoms

if comes in contact with allergen ___Staff was educated regard- ___Animals________________ ___Student will receive emergency ing allergies/symptoms/treat-____________________________ treatment as needed ___Administer medication as pre- ment

scribed by physician/911 call Date:_____________________ ___Airborne_______________ ___Other____________________________ ___Medical statement for students ___Medication was administered

requiring special meals form according to symptoms ___Other_________________ Date:_________________________________________________ ___Allergy aware environment

___Allergy aware environment___Other provided at school

Date:_____________________

___911 called as needed Date:_____________________

___Other Date:_____________________

NURSES NOTES

DATE INITIALS NURSING DIAGNOSIS OUTCOME/GOAL PLANNING & IMPLEMENTATION EVALUATIONALTERATION INSKIN INTEGRITY

Risk due to: ___Skin integrity intact or improving ___Repositioning of student every ___Student exhibited intact or two hours improving skin integrity

___Decreased mobility ___Student will express understand- Date:_____________________ ing of importance of nutrition/ ___Wound care/dressing change as

___Altered nutrition hydration/mobility in skin integrity ordered ___Student expressed understanding of importance of

___Incontinence ___Other ___Assure appropriate hydration nutrition/hydration/mobility in skin integrity

___Surgical incision ___Assure appropriate nutrition Date:_____________________

___Altered oxygenation ___Encourage mobilization ___Other Date:_____________________

___Pressure ___Instruct student of importance of nutrition/hydration/mobility

___Vascular in nature___Appliances as prescribed

___Other___Other

NURSES NOTES

DATE INITIALS NURSING DIAGNOSIS OUTCOME/GOAL PLANNING & IMPLEMENTATION EVALUATIONALTERATION IN ELIMINATION

Altered elimination related to: ___Student will maintain adequate ___Catheterize as needed ___Student had adequate GI GI elimination while at school elimination at school

___Incontinence ___Frequent bathroom visits Date:________________________Student will maintain adequate

___Diarrhea urinary elimination while at school ___Encourage fluids ___Student had adequate urinary elimination at school

___Constipation ___ Student will be able to care for ___Ostomy appliance care and Date:_____________________ GI/GU appliances while at school maintenance

___Ostomy as per age appropriateness ___Student provided self care Type_____________________ ___Monitor bowel movements while at school

___Student will have minimal Date:________________________Urinary retention accidents while at school ___Offer privacy bathroom in the

nurse's office ___Student had minimal accidents___Infection ___Student will have necessary while at school

supplies for care at school ___Assist with change of clothes Date:________________________Disease process including a change of clothes

___Student provided necessary___Other ___Other ___Other supplies while at school

Date:_____________________

___Student came to nurse's bathroom while at school Date:_____________________

___Other Date:_____________________

NURSES NOTES

DATE INITIALS NURSING DIAGNOSIS OUTCOME/GOAL PLANNING & IMPLEMENTATION EVALUATIONIMPAIRED PHYSICAL MOBILITY

___Fear of falling ___Student will maintain optimal ___Assist student as needed ___Student maintained a safe level of physical mobility status while at school

___Pain ___Assistive devices as needed Date:________________________Other

___Balance deficit ___Pain management as prescribed ___Student requested pain medi- by physician cation appropriately resulting

___Gait disturbance in minimal discomfort___Early dismissal from class to Date:_____________________

Limited functional ability: avoid hall congestion___Student used assistive devices

___Weakness ___Student assistant to help carry as needed personal items Date:_____________________

___Paralysis___Other ___Other

___Injury Date:_____________________

___Other

NURSES NOTES


NEUROLOGICAL STATUS

Disease process:______________ ___Student will perform at highest ___Encourage student to strive to ___Student performance at school____________________________ level of function reach maximum level of daily reflected maximum ability____________________________ living Date:_________________________________________________ ___Student will remain safe at school

during seizure activity ___Monitor student's seizure ___No injuries were reported bySeizure type: activity student as a result of seizure___Grand Mal/Tonic-Clonic ___Nurse will have proper documen- Date:_____________________

tation of seizure activity at school ___Log seizure activity on flow sheet___Absence/Petit Mal ___Nurse maintained proper

___Other ___Medication as prescribed by documentation regarding___Simple Partial physician seizure activity

Date:________________________Complex Partial/Psychomotor ___Provide a safe environment for

student during seizure ___Other___Atonic/Drop Attacks Date:_____________________

___Provide for privacy of student___Myoclonic during seizure activity

___Other ___Other

NURSES NOTES

DATE INITIALS NURSING DIAGNOSIS OUTCOME/GOAL PLANNING & IMPLEMENTATION EVALUATIONPAIN MANAGEMENT

___Acute pain Student will experience diminished ___Assess pain level per appropriate Student experienced diminishedpain as evidenced by: pain scale pain as evidenced by:

___Chronic pain___Verbalization of decrease in or ___Administer pain medication as ___Verbalized decrease in or

___Musculoskeletal disorder absence of pain ordered and evaluate effective- absence of pain ness Date:_____________________

___Cancer ___Relaxed facial expression and body positioning ___Eliminate precipitating factors ___Exhibited relaxed facial ex-

___Post operative pain pression and body positioning___Increased participation in activities ___Teach student to request anal- Date:_____________________

___Pressure points gesic before pain is severe___Stable vital signs ___Exhibited increased partici-

___Migraines ___Decrease environmental stimuli pation in activities___Other Date:_____________________

___Headaches ___Implement non-med methods for reducing pain/promoting comfort ___Vital sign were stable

___Immobility *Slow rhythmic breathing Date:_____________________ *Repositioning on cot

___Other *Turn lights out ___Other Date:_____________________

___Other

NURSES NOTES

DATE INITIALS SIGNATURE AND TITLE NAME OF SCHOOL TEACHER DATE OF REVIEW

ADDITIONAL NOTES

FORM E

““““N ational D istrict of Character”N ational D istrict of Character”N ational D istrict of Character”N ational D istrict of Character”

_____________________

Date Dear Parent/Guardian:

We have a student in your child’s class that has a peanut/nut allergy. We are making every effort to ensure that his/her safety and health are not jeopardized. As a staff, we are becoming more familiar with putting in place effective strategies to address the child's needs in the classroom, on field trips, in the lunchroom and other areas while at school.

Prevention, of course, is the best approach and, therefore, we are requesting your cooperation in refraining from sending peanut/nut containing food products to school with your child for snack time. We have asked the students not to share their lunches, snacks or treats. Our concern is for foods where peanuts or nuts might be a "hidden" ingredient, and where cross-contamination may occur. In a classroom setting, cross-contamination is the greatest risk from this type of allergy.

We realize this request poses an inconvenience for you when providing your child's classroom snack; however, we sincerely appreciate your support and understanding of this potentially life-threatening allergy. We realize it is difficult at times to get children to eat a healthy snack, however, we hope you will understand the seriousness of an allergy. If your child consumes a peanut/nut product prior to arriving at school, please make every effort to wash the child’s hands and face.

With your co-operation we can minimize the risk of an allergic reaction, and create as safe a learning environment as possible for our students. Attached you will find a list of “safe” snacks that can be sent for the classroom treats.

Thank you for your support and understanding.

Please call me if I can be of assistance.

______________________________ ___________________ School Nurse Phone



_____________________


We have a student in your child’s grade level that has a peanut/nut allergy. We are making every effort to ensure that his/her safety and health are not jeopardized. As a staff, we are becoming more familiar with putting in place effective strategies to address the child's needs in the classroom, on field trips, in the lunchroom and other areas while at school.

Prevention, of course, is the best approach and, therefore, we are requesting your cooperation in refraining from sending peanut/nut containing food products to school with your child. We have asked the students not to share their lunches, snacks or treats. Our concern is for foods where peanuts or nuts might be a "hidden" ingredient, and where cross-contamination may occur. In a classroom setting, cross-contamination is the greatest risk from this type of allergy.

We realize this request poses an inconvenience for you when packing your child's snack and lunch; however, we sincerely appreciate your support and understanding of this potentially life-threatening allergy. We realize it is difficult at times to get children to eat a healthy snack, however, we hope you will understand the seriousness of an allergy. If your child consumes a peanut/nut product prior to arriving at school, please make every effort to wash the child’s hands and face.

With your co-operation we can minimize the risk of an allergic reaction, and create as safe a learning environment as possible for our students.






_____________________


We have a student in REACH that has a peanut/nut allergy. We are making every effort to ensure that his/her safety and health are not jeopardized. As a staff, we are becoming more familiar with putting in place effective strategies to address the child's needs in the classroom, on field trips, in the lunchroom and other areas while at school.

Prevention, of course, is the best approach and, therefore, we are requesting your cooperation in refraining from sending peanut/nut containing food products to school with your child. We have asked the students not to share their lunches, snacks or treats. Our concern is for foods where peanuts or nuts might be a "hidden" ingredient, and where cross-contamination may occur. In a classroom setting, cross-contamination is the greatest risk from this type of allergy.

We realize this request poses an inconvenience for you when packing your child's snack and lunch; however, we sincerely appreciate your support and understanding of this potentially life-threatening allergy. We realize it is difficult at times to get children to eat a healthy snack, however, we hope you will understand the seriousness of an allergy. If your child consumes a peanut/nut product prior to arriving at school, please make every effort to wash the child’s hands and face.

With your co-operation we can minimize the risk of an allergic reaction, and create as safe a learning environment as possible for our students.





INDIVIDUAL 504 NON-DISCRIMINATION PLAN

STUDENT INFORMATION

Name: Date of Birth:

School: Grade:

Parent/Guardian Name:

Address:

Phone: Email:

Case Manager:

Date of 504 Plan Meeting:

INFORMATION RELATING TO NATURE OF DISABILITY

1. Describe the student’s mental or physical impairment(s) that serve as the basis

for the student’s 504 disability and how the student’s impairment(s)

substantially limits a major life activity or activities.

2. Describe how the student’s 504 disability limits or impacts the student in the

educational setting.

FORM G

3. Summarize the existing and/or evaluation data that supported the

determination of a 504 disability.

4. Is the student’s impairment(s) episodic or in remission? _____ Yes _____

If yes, state the frequency and impact of the appearance of the impairment’s

symptoms or characteristics. Also describe how and when the episodic nature of

the impairment impacts or limits the student in the educational setting?

5. Is the student’s impairment(s) positively impacted by the use of any mitigating

measures? _____ Yes _____ No

If yes, describe what mitigating measures are in place and the impact of those

mitigating measures on the identified major life activity or activities:

6. Was the student’s multidisciplinary team able to determine through the review

of existing data or evaluation process the impact of the impairment(s) without

mitigating measures in place? _____ Yes _____ No

If Yes, describe the difference, if any, of the impact of the impairment(s) with

and without mitigating measures:

PROVISION OF FAPE

The student who is the subject of this individualized plan has been determined to be a student

with a 504 disability and entitled to the provision of a free appropriate public education (FAPE) as

defined by the federal 504 regulations. Pursuant to those regulations, FAPE is defined as the

provision of regular or special education or related aids and services that are designed to meet

the needs of the disabled student as adequately as the needs of nondisabled students.

After the student has been determined to have a 504 disability, the student’s multidisciplinary

team should convene and answer the following questions to determine how FAPE will be

provided to the student who is the subject of this plan.

7. If the student regularly and consistently attends school with mitigating measures

in place, does the student require the provision of any regular or special

education and/or related aids and services other than those generally provided

to the District’s nondisabled students to have his/her needs met as adequately

as the needs of the nondisabled students in the District?

_____ Yes _____ No

If the answer to the above question is no, the student is considered to be 504

disabled, he/she is entitled to the procedural protections of that law, and his/her

parents are entitled to the rights accorded to them as outlined in the 504 federal

regulations and the District’s 504 Procedural Safeguards, but the student has no

current needs that require additional regular education, special education

and/or related aids or services to receive FAPE under Section 504.

If the answer to the above question is yes, proceed to question 8.

8. With or without reference to mitigating measures and in order to receive FAPE

under Section 504, does the student only require any of the following programs,

aids, services, accommodations, supports, or interventions that are available to

the District’s nondisabled students on an as-needed basis? _____ Yes_____ No

If the answer is Yes, mark which of the following programs, aids, services,

accommodations, supports and/or interventions are necessary for the student to

receive FAPE: [Note: The following are intended only as illustration. Each

District must tailor this section of the 504 Plan to be consistent with what the

District makes available to its general education population].

_____ Individual Health Plan

_____ Educational Support Plan/Success Plan

_____ Regulation Education Interventions through RTI

_____ Regular Education Behavior Contract or Support Plan

_____ Positive Behavior Support Program/BIST

_____ Title I Remedial Programs

_____ Alternative Program

_____ Administration of Medication

_____ Access to School Health Services or Nursing Services

_____ Other: (Describe)

If the answer to question 8 is Yes, the indicated programs, aids, services,

accommodations, supports or interventions constitute the provision of FAPE to

this student under Section 504. If relevant, a copy of any written plans or

programs should be attached. If no written plan or program is available, provide

a description of the program, aids, services, accommodations, supports or

interventions that are or will be in place.

If the answer to question 8 is No, the student’s multidisciplinary team should

consider the provision of FAPE based on question 9 below.

9. With or without reference to mitigating measures, does the student need the

provision of programs, aids, services, accommodations, supports and/or

interventions that are not generally available to the District’s nondisabled

students and are beyond those described under question 8 above to have

his/her needs met as adequately as those of his/her nondisabled peers?

_____ Yes _____ No

If Yes, indicate below what additional programs, aids, services, accommodations,

supports or interventions that are not available to the District’s nondisabled

students this student needs for the provision of FAPE. If the student exhibits

behaviors that are a manifestation of his/her 504 disability, the team should

consider whether an individualized behavior plan is necessary for the provision

of FAPE.

Additional Programs, Aids, Services, Supports, Interventions, Accommodations Deemed

Necessary by the Multidisciplinary Team for the Provision of FAPE:

Student

Need

Description

of Services

Location

Responsible

Person

Implemen-

tation Dates

Eval.

Criteria

10. Describe the student’s educational placement and the student’s least restrictive

environment:

11. Does the student require the provision of any related services to receive FAPE?

_____ Yes _____ No

If the answer to question 11 is Yes, describe the related services to be provided,

including the amount, duration, frequency and location of such services. If relevant,

include any transportation that the student requires as a necessary related services.

12. Anticipated 504 Plan Review Date:

13. List of Participants (Name and Role/Title:)

___________________________________ ____________________________________

___________________________________ ____________________________________

___________________________________ ___________________________________

___________________________________ ____________________________________

___________________________________ ____________________________________

I, the parent/legal guardian of the student named above, was given the opportunity to

participate in the development of this 504 Plan and agree with the Plan as developed. I

also have been given a copy of my 504 Procedural Safeguards and have had the

opportunity to review those safeguards.

____________________________________ ___________________________________

Parent/Guardian Signature Date

14. The Case Manager is responsible for informing all responsible teachers, staff

and administration of their responsibilities for the implementation of this 504

Plan. Please indicate below the date and manner in which this information

was provided:

Date Informed Person Informed Manner of Presentation Case Manager

Initials

The Case manager also is responsible for monitoring to ensure that all teachers, staff

and administrators are implementing the Plan as written

Copy of 504 Plan given to parents on _____________by__________________________

[OPTIONAL]: ACCOMMODATIONS FOR EXTRACURRICULAR AND NONACADEMIC

ACTIVITIES:

The student for whom this Plan was developed has an equal opportunity to participate

in the District’s nonacademic and extracurricular activities. Unless determined by the

student’s 504 multidisciplinary team that a particular extracurricular or nonacademic

activity is necessary for the provision of FAPE, the supports and/or accommodations

listed below are not necessary for the provision of FAPE to this student, but are listed

for the sole purpose of allowing the student the required equal opportunity.

Will the student have the opportunity to participate in nonacademic/extracurricular

activities with his/her nondisabled peers? _____ Yes

_____ Yes, with supports. (Describe)

_____ No. Explanation must be provided:

SECTION 504 STAFF REFERRAL FORM

Name of Staff Member Referring Student: _____________________________________

Date of Referral: __________________________________________________________

STUDENT INFORMATION

Name of Student:

Date of Birth:

School Attending:

Grade:

Parent/Guardian Name:

Address:

Phone Number: Email:

MEDICAL INFORMATION Note: A medical diagnosis is not required to support the existence

of a 504 disability.

Does the student have any medical conditions or diagnoses of which you are aware:

REASON FOR REFERRAL: Note: A disability exists under 504 only if the student has a mental

or physical impairment that substantially limits one or more major life activities.

Impairment or Suspected Impairment(s):

Major Life Activities Possibly Impacted:

Describe Possible Impact of Impairment(s) on the Major Life Activities Listed:

FORM H

Diagnosis: Diagnosed By: Date:

Diagnosis: Diagnosed By:

Date:

Diagnosis: Diagnosed By: Date:

Is the student on any medication(s)? (Please list if known)

Describe the impact of the medication(s) on the student, if known:

Does the student wear glasses, contacts or other corrective lenses?

Does the student wear an assistive hearing device?

Does the student utilize any other mitigating measures that positively impact the student

educationally? A mitigating measure is something that helps to improve the impact of the

impairment. If yes, please list and describe the impact of each mitigating measure.

EDUCATIONAL INFORMATION

List all schools attended and the dates of attendance at each, if known:

Has the student ever been home schooled? If Yes, please provide dates, if known:

CULTURAL, ECONOMIC, AND ENVIRONMENTAL FACTORS

Describe any cultural, economic, or environmental factors that you believe may have impacted or

limited the student at school or in the school environment:

EXISTING EDUCATIONAL INFORMATION

Current School Year Attendance: Days Present: Days Absent:

List reasons for absences:

Has the student ever been on an IEP, 504 or other educational support plan? If yes, please

describe:

Is the student considered to be bilingual or is English the student’s second language?

List any alternative programs in which the student has participated at this or other school districts

and the dates of participation: (Examples include but are not limited to Title I programs,

Alternative School, English as a Second Language Programs, Response to Intervention programs,

Gifted, Tutoring, Vocational)

Past School Year Attendance: Days Present: Days Absent:

List reasons for absences:

Existing Testing Data: List or attach a copy of the student’s State or District-wide testing data, the

results of any evaluations previously administered for IDEA or 504, and any relevant curriculum

based or classroom assessments.

Current Grades:

Promotion/Retention: Has the student ever been retained? _____ Yes _____ No

Describe grades and dates, if known:

Academic Characteristics: The Current or Prior Year’s Teachers should estimate the student’s

current grade levels in the following academic areas and state the basis for that estimate.

Reading Fluency Reading Comprehension Basic Reading

Math Calculation Math Reasoning Spelling

Written Expression Other

General Education Interventions:

List any generally available general education interventions that have been used with this student

and indicate on a scale of 1 to 3 (with 1 being of no assistance and 3 being of great help) whether

the interventions assisted the student to be successful in regular education.

_____ Modified instructional methods (list) 1 2 3

_____ Modified instructional pacing 1 2 3

_____ Modified instructional materials 1 2 3

_____ Reteaching 1 2 3

_____ Parent conferences 1 2 3

_____ Behavior contract or plan 1 2 3

_____ Other (list) 1 2 3

Discipline: Attach a copy of student’s disciplinary records for the past two school years.

For Classroom Teacher Completion: Based on your knowledge and observation of this student,

please rate this student’s performance in comparison with the average student in the classroom.

Observations 1-Unsatisfactory to 5-Exellent

Classroom Work Homework Tests

Reading Math Written Expression

Following Oral Directions

Following Written

Directions

Attendance

Attention Span

Organization

Behavior/Compliance

For Administrator Use Only:

Date Referral Received:

Person Receiving:

District Action:

� IDEA Disability Suspected – Refer to Special Education Department

� 504 Disability Suspected – Convene Team to Conduct Review of Existing Data

� No Disability Suspected

� No Disability Suspected - Recommend General Education Interventions and/ or

referral to [examples – Teacher Support Team; RTI Process]

Date of District Action:

Individual(s) participating:

FORM J 1st Meeting Scheduled for: ________________ Revised September 2010

Student Success Team Initial SST Referral Form

Student: ______________________________________ Date: _______________________________________ Teacher: _______________________________ Grade: ________ D.O.B. _____________ Age: _________ Student Assets: _________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Concerns: _____________________________________________________________________________________

Academic: Reading Decoding Comprehension Fluency Writing Spelling Arithmetic Short term memory Study skills Organization Lack of Motivation Poor test performance Other ____________________________

_______________________________________________________________________________________________ Social: Aggression Disruptions Withdrawal Non-compliance

Social Skills Impulsivity Attention Blames others/defensive Other _____________________________

_______________________________________________________________________________________________ Emotional: Flat affect Nervous/tense Mood swings Extended sadness

Apathy Loner Low self-esteem Other _______________ Other: Home concerns Attendance Other ____________________________________ ______________________________________________________________________________________________________________________

Previous Assessment Data: (Please attach) MAP Y _____ N _____ STAR Y _____ N _____ Brigance Y _____ N _____ Gates Y _____ N _____

CMS Y _____ N _____ Report Card Y _____ N _____

_______________________________________________________________________________________________ Screening Information:

Review Cumulative Folder Y _____ N _____ Check Medical Records Y _____ N _____ Contact the parents Y _____ N _____

Talk with last year’s/other teachers Y _____ N _____ Talk with previous school (if applicable) Y _____ N _____ Talk with student Y _____ N _____ Talk with pertinent personnel Y _____ N _____

(i.e. counselor, doctor, case worker, etc.) Student screened in the following areas: Vision Y _____ N _____ Results ____________________________ Hearing Y _____ N _____ Results ____________________________ General Health Y _____ N _____ Results ____________________________ Motor Y _____ N _____ Results ____________________________ _______________________________________________________________________________________________ Information Required - Bring to Meeting Yes/No Cumulative Folder Review Yes No Medical Records Yes No Student Assessment Data – including current grades Yes No Work Samples Yes No

FORM M RESOURCES Accommodating Children with Special Dietary Needs (USDA) http://www.fns.usda.gov/cnd/Guidance/special_dietary_needs.pdf Allergy and Asthma Foundation of America http://www.aafa.org/ American Academy of Allergy, Asthma, and Immunology http://www.aaaai.org/ American Academy of Pediatrics http://www.aap.org/ American Dietetic Association http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/index.html American Latex Allergy Association http://www.latexallergyresources.org/ Center for Chronic Disease Prevention and Health Promotion: DASH Healthy Youth Food Allergies http://www.cdc.gov/HealthyYouth/foodallergies/ Epi-pen Training Information http://www.epipen.com/how-to-use-epipen Department of Health and Senior Services (DHSS) http://health.mo.gov Food Allergy and Anaphylaxis Network (FAAN) http://www.foodallergy.org/ FAAN Sample Food Allergy Action Plan http://www.foodallergy.org/files/FAAP.pdf FAAN School Guidelines for Managing Students with Food Allergies http://www.foodallergy.org/files/media/food-allergy--anaphylaxis-network-guidelines/SchoolGuidelines.pdf FAAN Back to School Kit http://www.foodallergy.org/section/back-to-school-tool-kit FAAN Order Information for Epi-pen Trainers http://www.foodallergy.org/members/msascart-ProductInfo?productcd=EPI Food Allergy Initiative http://www.foodallergyinitiative.org/section_home.cfm?section_id=7 Jefferson County Health Department (JCHD) http://www.jeffcohealthorg Liberty Public School District Life Threatening Allergy Policy and Guidelines http://www.schoolnutrition.org/uploadedFiles/School_Nutrition/104_CareerEducation/ContinuingEducation/Webinars/FoodAllergyWebinar-Allergy_policy_guidelines.pdf?n=9295 National Association of School Nurses http://www.nasn.org/

National Library of Medicine-―Medlineplus‖ http://www.nlm.nih.gov/medlineplus/foodallergy.html New York Food Allergy Training Module for Nurses http://schoolhealthservices.org/tool_kit.cfm?subpage=97 New York State School Health Services Food Allergy Guidelines http://www.schoolhealthservicesny.com/uploads/Anaphylaxis%20Final%206-25-08.pdf Safe@School Partners http://www.foodallergysmart.org/index.htm Washington FEAST (Food Education and Allergy Support Team) http://www.wafeast.org/ Spokane Public School District Food Allergy Guidelines http://www.spokaneschools.org/17422041383659530/blank/browse.asp?a=383&BMDRN=2000&BCOB=0&c=55889 Washington State Office of Public Instruction (OSPI) Guidelines for Care of Students with Anaphylaxis http://www.k12.wa.us/HealthServices/Publications/09-0009.aspx

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