HomeMy WebLinkAboutOCDSB 963 Plan of Care Asthma 2020OCDSB 963 (Asthma) 1
OCDSB 963: PLAN OF CARE FOR STUDENTS WITH ASTHMA
(References: P.108.SCO, PR.548.SCO, and PR.547.SCO)
The information on this form is collected annually and deemed valid until August 31 of
each school year.
Student Information (Attach a recent photo of student)
Student Name (first, middle, last):
Student Date of Birth:
School Name:
Grade:
Student Number:
Teacher Name:
Parent/Guardian Information (required if student is under 18 years of age)
Parent/Guardian First and Last Name:
Home Phone Number:
Parent Email Address:
Emergency Contacts (Please list in order of priority)
Name Relationship Daytime Phone Alternate Phone Email
1.
2.
3.
Primary Healthcare Provider Information
Name:
Telephone number:
Profession/Role:
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Healthcare Specialist Information
Same as Primary Healthcare Provider.
Different from Primary Healthcare Provider (Complete the following information)
Name:
Telephone number:
Profession/Role:
Physician
Nurse Practitioner
Registered Nurse
Pharmacist
Respiratory Therapist
Certified Respiratory Educator
Certified Asthma Educator
Other. Please specify:
I/We authorize the school staff to contact the above health care provider as
required to attend to the well-being of the student.
Please attach the most recent, original instructions, prescriptions, and labels
pertaining to each medication. Date of prescription/notes must be captured.
Daily/Routine Asthma Management
KNOWN ASTHMA TRIGGERS (check all that apply)
Colds/flu/illness
Physical activity/exercise
Pet dander
Smoke (e.g. tobacco, fire,
cannabis,second-hand smoke)
Pollen
Mould
Dust
Cold weather
Change in weather
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Strong smells
Allergies
Anaphylaxis
Other:
Please specify
AVOIDANCE INSTRUCTIONS
OTHER ACCOMMODATION (e.g. during nutrition breaks, field trips)
Reliever Inhaler
Use the provided reliever inhaler in the dose of (number of puffs)
when the student experiences the following asthma symptoms (Check all that
apply)
Continuous coughing
Trouble breathing
Chest tightness
Wheezing (whistling sound in chest)
Student may also be restless, irritable and/or quiet
Other (explain):
Please check the type of reliever inhaler the student uses:
Salbutamol (e.g. Ventolin)
Airomir
Ventolin
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Bricanyl
Other (specify):
Is spacer (valved holding chamber) provided?
Yes
No
Do you authorize the student to carry the reliever inhaler at all times?
Yes. Reliever inhaler is kept in the student’s:
Pocket
Case/pouch
Backpack/fanny pack
Other (specify):
No. Please specify where the reliever inhaler is kept (e.g. name of an individual or
locker combination):
Controller Inhaler
Does a controller inhaler have to be administered during school hours?
Yes
No
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Controller Medication Use:
Use/Administrator (Name of
Medication)
In the dose of At the following times
Special Instructions for Administration:
Duration of Medication Regime:
Caution of Notable Side Effects:
Do you authorize the student to carry the controller inhaler at all times?
Yes. Controller inhaler is kept in the student’s:
Pocket
Case/pouch
Backpack/fanny pack
Other (specify):
No. Please specify where the controller inhaler is kept (e.g. name of an individual or
locker combination):
Please specify location of backup inhalers in school:
Storage Cautions (if any):
Disposal Instructions:
I/We acknowledge that it is my/our responsibility to submit enough backup
medication and medical supplies to school and to track the expiration date.
Parent(s)/Guardian(s) Authorization to Administer Medication
The administration of medication involves certain elements of risk, including, but not
limited to illness, adverse reactions or other complications. Reactions caused by the
administration of any medication can occur without fault on any party; the student, or the
OCDSB 963 (Asthma) 6
OCDSB or its employees or agents. By requesting and consenting to the administration
of medication by an employee of the OCDSB, or by authorizing the self-administration
of medication by the student, you are assuming any associated risks.
In life-threatening emergencies, staff will administer prescribed medication to
students “in loco parentis” and not as healthcare professionals.
I/We authorize the OCDSB staff to administer prescribed medication to the student
as prescribed. I/We understand that OCDSB staff is not medically trained to administer
medication and bear sole responsibility for any adverse reaction that might occur
following the administration of medication.
The student is capable of administering their own medication. I/We bear sole
responsibility for any adverse reaction that might occur following the self-administration
of medication.
Consent to Release Information
Does the student use OSTA bus on a regular basis?
Yes. A copy of the Student Care Plan will be shared with OSTA.
No.
I/We give consent for the school to share this Plan of Care as necessary with
individuals in direct contact with the student to attend to their well-being and medical
needs at school and during school activities. This may include school and office
staff, occasional staff, OSTA, contracted bus operators and bus drivers, before- and
after-school program staff. This plan will be posted in identified areas of the school
for emergency response purposes.
I confirm that the information herein is accurate and up to date. I understand that I
must re-submit this form in case of any changes to the student’s medication,
condition, level of independence, or treatment plan.
The personal information of this form is collected under the authority of the Education Act (RSO. 1990 c.E.2) and in
accordance with the Municipal Freedom of Information and Protection of Privacy Act (RSO. 1990 c.M56), as
amended. It will be used to establish the Ontario Student Record [OSR] and for student and education related
purposes such as registration, administration, communication, collection of fees, data reporting, and Student
Transportation Services. In addition, the information may be used or disclosed to comply with legislation, for
compelling circumstances affecting health and safety or discipline, as required in circumstances related to allow
enforcement matters, and with third parties in accordance with established service agreements or in accordance with
any other Act. Questions or concerns should be directed to the school principal or the Board’s Freedom of
Information Coordinator, Ottawa-Carleton District School Board, 133 Greenbank Road, Ottawa, Ontario, K2H 6L3,
Telephone 613-596-8211 ext. 8607.
OCDSB 963 (Asthma) 7
Parent(s)/guardian(s)/Adult Student Name:
Parent(s)/guardian(s)/Adult Student signature:
Date:
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