HomeMy WebLinkAboutOCDSB 963 Plan of Care Epilepsy 2020OCDSB 963 (Epilepsy) 1
OCDSB 963: PLAN OF CARE FOR STUDENTS WITH
EPILEPSY/SEIZURE DISORDER
(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:
OCDSB 963 (Epilepsy) 2
Epilepsy/Seizure Disorder 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 for Epilepsy/Seizure Disorders Management
KNOWN SEIZURE TRIGGERS (check all that apply)
Change in Weather
Changes in Diet
Electronic Stimulation (TV, Videos, Fluorescent Lights)
Hormonal fluctuations
Illness
Improper Medication Balance
OCDSB 963 (Epilepsy) 3
Inactivity
Lack of sleep
Stress
Any other medical condition or allergy?
Other triggers:
Please complete as applicable
Type of
Seizure
Symptoms Action to Take (e.g.
description of dietary
therapy, risks to be
mitigated, trigger
avoidance)
Frequency of
Seizure Activity
(daily, monthly, or
annually)
Typical
Seizure
Duration
Date of
Last
Seizure
Non-
Convulsive
Seizure
Convulsive
Seizure
Other.
Please list
type
OTHER ACCOMMODATION (e.g. during nutrition breaks, field trips, protective equipment,
post-incident care)
OCDSB 963 (Epilepsy) 4
Emergency Procedures FIRST AID
PROCEDURE
Medication
Has a routine or rescue medication been prescribed to the student?
Yes.
No.
Medication Details
● Name of medication:
● Prescription Number:
● Dosage of Medication:
● Time of Administration:
● Instructions for Administration:
● Duration of Medication Regime:
● Possible Side Effects:
Do you authorize the student to carry the required medication at all times?
Yes. The medication is kept in the student’s:
Pocket
Case/pouch
Backpack/fanny pack
Other (specify)
OCDSB 963 (Epilepsy) 5
No. Please specify where medication is kept (e.g. name of an individual or locker
combination):
Please specify location of backup medication in school:
Storage requirements (if any):
Disposal Instructions:
I/We acknowledge that it is my/our responsibility to submit enough backup
medication to school and to track the expiration date.
Parent(s)/Guardian(s) Authorization to Administer Prescribed 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, including the student, or the 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”, 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.
OCDSB 963 (Epilepsy) 6
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.
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.
Parent(s)/guardian(s)/Adult Student Name:
Parent(s)/guardian(s)/Adult Student signature:
Date:
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.
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