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TRANSCRIPT
Date Registration Completed ________________
SPECIAL EVENT CHILD CARE REGISTRATION FORM To be completed, signed, and placed on file in the facility on the first day and updated as changes occur and at least annually
CHILD INFORMATION: Date of Birth: ____________________ Full Name:________________________________________________________________________________________________________
Last First Middle Nickname Child's Physical Address:__________________________________________________________________________________________________ FAMILY INFORMATION: Child lives with: ___________________________________________________ Father/Guardian’s Name ____________________________________________________ Home Phone ______________________ Address (if different from child’s) ____________________________________________________ Zip Code __________________ Work Phone __________________________________________________________ Cell Phone_________________________
Mother/Guardian’s Name ___________________________________________________ Home Phone ______________________ Address (if different from child’s) ____________________________________________________ Zip Code __________________ Work Phone __________________________________________________________ Cell Phone_________________________
CONTACTS: Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this registration form. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals. _____________________________________________________________________________________________________ Name Relationship Address Phone Number _____________________________________________________________________________________________________ Name Relationship Address Phone Number _____________________________________________________________________________________________________ Name Relationship Address Phone Number
HEALTH CARE NEEDS: For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan must be completed and attached to this registration form. The medical action plan must be completed by the child’s parent or health care professional. Is there a medical action plan attached? Yes__ No__
List any allergies and the symptoms and type of response required for allergic reactions. _______________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________ List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns __________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List any particular fears or unique behavior characteristics the child has_____________________________________________________________ _____________________________________________________________________________________________________________________ List any types of medication taken for health care needs_________________________________________________________________________ Share any other information that has a direct bearing on assuring safe medical treatment for your child____________________________________ _____________________________________________________________________________________________________________________
I, as the parent/guardian, agree that the operator, YMCA of Western North Carolina, may authorize the physician of his/ her choice to provide emergency care in the event that neither I nor the family physician can be contacted immediately.I authorize for my child to be transported in the case of an emergency when medical attention by a physician is necessary. I understand that the YMCA staff is never to transport children in their personal vehicles at any time and a hospital or fire/emergency department will always be contacted.My child has permission to participate in all YMCA of Western North Carolina youth activities, including field trips and transportation where applicable. I grant permission for photographs, or other media, which include my child, quotes and written work to be used in media releases which benefit the YMCA. The Y does not administer over-the-counter medications to children. Y staff will administer prescription medications in their original container with the child’s name, accompanied by the appropriate medical action plan.I understand and agree to abide by the attached policies and procedures for Special Event Child Care.Accordingly, neither the YMCA nor any of its agents, employees, servants, community partners or invitees shall be liable to me or any of my family, agents, employees, servants, or invitees for any damage to persons or property when and to the extent that any such damage or injury may be caused, either proximately or remotely, wholly or in part, by any act or omission, whether negligent or not, of the YMCA or any of its agents, servants, community partners or invitees or due to the condition or design or any defect in the building, its mechanical systems, or its equipment.
Signature of Parent/Guardian_______________________________________________________________Date_______________
Special Event Child Care Policies Attendance, Drop-Off, and Pick-Up Policies For Special Event Child Care, be prepared to take additional time during drop-off to complete or
correct necessary paperwork.
An authorized adult must sign children in and out of program. Failure to sign your child(ren) in and
out may result in their removal from the program. Before the child(ren) can leave the YMCA area, the adult must sign them out and provide picture identification.
Only those people listed on the registration form will be allowed to pick up the child(ren). Additions
to the list can be made at any time by the parent(s)/guardian(s) listed on the registration. \ID is
required at pick-up time. This policy is for the safety of your child(ren).
Program Operating Hours/Dates Child care will be provided for this Special Event on November 16th, 2019 from 8:30 AM to 5:00
PM.
Growing Leaders Behavior Management Policy Y staff will use positive behavior management techniques that are developmentally appropriate and
that adhere to the Y’s four core values of caring, honesty, respect, and responsibility.
It is important that staff maintain good order, high expectations, and appropriate discipline in all programming. Top objectives in all YMCA programs are safety and a positive atmosphere for
learning and developing social skills. The YMCA makes every effort to help campers understand
clear definitions of acceptable and unacceptable behavior. All children must be able to follow behavior expectations and participate in all program activities.
Parents/guardians are required to inform the YMCA program staff in writing of any special
circumstances that may affect the youth’s ability to participate fully and to stay within the
guidelines of acceptable behavior, including any behavioral problems and psychological, medical, or physical conditions. YMCA staff are not responsible for providing a one-on-one counselor.
Expectations for Children Children are expected to:
• Participate in age-appropriate group
activities
• Cooperate with staff and follow
directions
• Respect other students and staff,
equipment, facilities, and themselves
• Maintain a positive attitude
• Stay in program areas and with
designated group
• Use appropriate language
Behavior Management Techniques Y staff will:
• Involve the children in the
development of the “house rules”
• Maintain consistent behavior
expectations and reinforce the Y’s
four core values
• Guide children by setting clear,
consistent, and fair limits for program
behavior
• Use natural and logical consequences
• Redirect children to more acceptable
behavior or an activity
• Use positive reinforcement, including
a positive behavior recognition
program
• Make eye contact and listen when
children talk about their feelings and
frustrations
• Guide children to resolve their own
conflicts through the use of conflict
resolution skills
• Use effective praise that is
immediate, sincere, and specific
• Modify and structure the environment
to attempt to prevent problems before they occur
Behavior Management Action Steps Y staff will work with children and families in the following ways:
1. If the youth is unable to comply with the behavior expectations, staff will give one warning
and attempt to redirect behavior by giving the child positive choices. Staff will never use
any form of corporal punishment.
2. If after the first warning the youth is still unable to comply with the behavior expectations, staff will use logical consequences and positive discipline to develop a behavioral plan with
the child.
3. If, after these interventions, the child is unable to comply with the YMCA behavior
expectations, staff will call parents/guardians. They will be required to pick up the camper early from program and sign a write-up form.
4. If the youth’s behavior continues to be disruptive and/or unsafe, the youth will be subject
to suspension or dismissal.
All suspensions require a meeting with the program director. At this meeting a behavior contract
will be established and signed by the child, parent, and staff before the child may return to the program.
Three behavior write-ups in any single semester or summer may result in suspension.
Certain behaviors will result in an immediate parent call, suspension, or removal from the program:
• Any actions that threaten the physical/emotional safety of the child, other youth, or staff
• Possession of a weapon of any kind
• Vandalism, destruction, or theft of YMCA or schools’ property
• Sexual misconduct
• Running away from designated group area
• Parent refusal to sign a discipline write-up form.
The parent/guardian is responsible for contacting the youth development director to set up an
appointment to discuss the child’s behavior before the child can return to the program.
Suspension Serious behavior problems will result in immediate suspension from the program. If the child is
reinstated and then receives a fourth behavior write-up, the child will be suspended immediately. If
necessary, the parent will be notified to pick up the child immediately. Upon the fourth report, the child will be removed from the program without the right of reinstatement during the program year.
Removal Y summer day camp programs cannot serve children who display chronically disruptive behavior.
Chronically disruptive behavior is defined as verbal or physical activity that may include, but is not
limited to:
• behavior that requires constant attention from the staff
• behavior that inflicts physical or emotional harm on other children or self
• behavior that is abusive toward the staff and/or shows that a camper is ignoring or
disobeying the rules
If a child cannot adjust to the program and behave appropriately, the child may not be able to
remain enrolled.
Reasonable efforts will be made to assist children in adjusting to the program setting.
Children with Special Needs The YMCA of Western North Carolina operates within the provisions of all applicable laws, including
those that provide protection to individuals with disabilities as well as to providers who care for
such individuals. Y programs welcome all children to the extent they are reasonably able to do so. A child who requires measures that constitute a fundamental alteration to the program or other
undue hardship, or a child who poses a direct threat to the health and safety of others, will not be
able to participate in the program.
Before a child’s admittance to the program, it is imperative that a YMCA youth development director make an individualized assessment as to whether the program meets the particular needs
of the child within the noted guidelines. Upon receiving the child’s registration form, our staff will
be in contact with the parents/guardians for a preliminary intake interview to gather all necessary and pertinent information to serve the participant to the best of our abilities within the parameters
of the program design.
If Y staff and/or the parents or guardians feel it necessary, a meeting will be scheduled for the Y
staff and the parents/guardians to discuss the situation.
Upon your child’s enrollment in the program, the youth development director will review the Individualized Care Plan (ICP) within two business days and schedule a parent consultation, if
needed, so the staff understands the best ways to provide care for your child. The ICP will also
note any special accommodations that are necessary to ensure the child’s success in the program.
This information will be shared with site staff, and follow-up calls and/or meetings with program coordinators will be arranged on an as-needed basis.
Health and Safety Medication Policy The Y does not administer over-the-counter medications to children. Y staff will administer
prescription medications in their original container with the child’s name, accompanied by a
Medication Release Authorization form that has been completed and signed by a parent/guardian and includes the following information:
• Child’s name
• Type of medication
• Physician’s name
• Instructions on amount of dosage (must match instructions on container)
• Time to be given (cannot write “as needed”)
• Number of days to be administered (up to six months for ongoing medications)
• Possible side effects
Please note that Y staff are NOT allowed to give the first dosage of any medication. If a child refuses medication, the incident will be documented and discussed with the child’s parent/guardian.
All medication on site is to be checked in with the site director on duty so it can be properly locked
for the safety of the children.
Insulin/Inhalers/EpiPens Children are not allowed to keep insulin, inhalers, or EpiPens in their backpacks or with them while attending the program.
Should your child require insulin, an inhaler, or an EpiPen, Y staff will keep that medication on their
person at all times. The same medication authorization release is required.
Such medications are to be given directly to the site director. We recognize the need for immediate access and therefore do not keep these medications locked as we do with all other forms of medication.
If a child needs his/her EpiPen, the child will insert the EpiPen and Y staff will contact 911 and the
child’s parent/guardian immediately.
Sunscreen and Hand Sanitizer If you choose to send sunscreen, it must be noted on your child’s registration form and be labeled
appropriately in a zip-top bag with child’s name and date, and the appropriate over-the-counter
medication authorization. All sunscreen is kept out of reach of children.
Sick or Ill Children To ensure the well-being of all children, please be considerate. If your child is too sick to go outside, he/she is too sick to attend child care.
Any child showing or developing symptoms such as fever, rash, diarrhea, or vomiting will be sent
home. Y staff will contact parents/guardians for immediate pick up.
Contagious Illnesses/Conditions If a child has a confirmed case of a contagious illness/condition, he/she must be kept at home and the condition reported to the site director. If a child exhibits symptoms of any contagious
illness/condition, Y staff will contact the parent/guardian and require them to pick up their child immediately. At the discretion of the site director, parents/guardians may be asked to submit a
doctor’s statement before the child returns to the site.
Examples of contagious illnesses and conditions include:
• Strep throat
• Chicken pox
• Hand, foot, and mouth disease
• Impetigo
• Lice
Emergency Medical Care The health and safety of the children in our care is our top priority. Even so, young children are often testing their physical limits, making injuries inevitable. Y staff will verbally inform parents/ guardians of any injuries. Y staff will call parents/ guardians if a child sustains a head injury.
In the event of a medical emergency or accident requiring a doctor’s treatment, we will contact parents/guardians immediately, and emergency personnel if necessary.
The YMCA of Western North Carolina may authorize the physician of its choice to provide emergency care in the event that a parent/guardian cannot be contacted immediately.
Parents/guardians authorize their child to be transported in the case of an emergency when medical
attention by a physician is necessary. Y staff will not transport children in their personal vehicles at any time and will always contact a hospital or fire/emergency department.
We, as the operator, YMCA of Western North Carolina, do agree to secure transportation to an
appropriate medical resource in the event of an emergency. In an emergency situation, other
children in the facility will be supervised by a responsible adult. Provisions will be made for adequate and appropriate rest and outdoor play.
Signature of Operator/YMCA Representative:
Paul Vest President and CEO
YMCA of Western North Carolina
Staff Relationships with Children Outside YMCA Programs Staff may not be alone with children they meet at the YMCA or in YMCA programs. This includes all forms of communication (phone calls, emails, instant messages, text messages, etc.).
Babysitting, hosting or attending sleepovers, and inviting staff members to a child’s home are
prohibited unless one of the following conditions exists:
• Staff and child’s family have a relationship that predates the staff member’s employment or
volunteering with the Y.
• Staff and the child’s family have a relationship that predates the child’s enrollment in the Y
program.
• Staff and the child or child’s family are related.
If you have an existing relationship with a Y staffer, you must contact Melissa Wiedeman at
[email protected] or 828 210 2278 to complete appropriate disclosures and
documentation.
The Y recognizes there are occasions when children ask a staff member to attend their sporting event, dance recital, etc. This is permitted only if it is a public event and the child and staff member
are never alone together. YMCA staff are NEVER allowed to transport children in their personal
vehicles.
Tobacco Policy The use of any product containing, made of, or derived from tobacco, including, but not limited to,
ecigarettes, cigars, little cigars, smokeless tobacco, and hookahs, is not permitted on the premises
of the child care program, on vehicles used to transport children, or during any off-premises activities.
Intoxicated Adult Policy Y staff will encourage any adult who appears intoxicated to call an emergency contact or another adult authorized to pick up the child or request a taxi to transport the adult and child home safely.
Parents who arrive at the Y who appear to be intoxicated will be encouraged to stay with us and
relax. If an adult chooses to leave, Y staff will call the police.
Custody Issues In the event of a difficult/dangerous custody situation where a court order is in place, please
contact Will Deter, [email protected], to set up guidelines regarding the release of your child.
You must have a copy of any court documents regarding the restriction of release of children in our care.
Parents/guardians are responsible for resolving any issues that may arise from their child’s
participation in our programs. The Y will not get involved in disputes. A child may be removed from
the program until the parents/guardians are able to resolve the differences.
Reporting Child Abuse North Carolina law requires any person who suspects child abuse or neglect to report the case to
the county Department of Social Services. Y staff will report all suspicions of child abuse or neglect.
How to Report a Problem Open communication is vital. We are here to address and work through problems and concerns. We encourage you to report all problems and concerns to your child’s site director. You can also direct
problems and concerns to:
Melissa Wiedeman, Vice President of Operations, K-12 Child Care YMCA of Western North Carolina
828 210 2278 or [email protected]
Medication Administration Permission 10A NCAC 09 .0803 (centers) and .1720(b) (family child care homes)
Parent/guardian completes the Medication Administration Permission and must sign and date it. The person accepting this form must attach the Medication Administration Record(s) to this form. Permission valid from date: To date:
Only complete this box if the medication is for a child who has a chronic medical condition or an allergy ☐ This document is written permission to administer this medication for up to 6 months. Specific chronic medical or allergic condition: Child has an ☐ Action Plan ☐ Individualized Health Care Plan Child’s full name: Date of birth: Medication Name: Expiration Date: Date(s) to give medication:
When to give medication (choose one): Give medication at these specific times (list times):
Give medication as-needed (write as-needed criteria below): List the specific symptoms or circumstances needed to give the medication and how often it can be given. For example: If Suzy has a rash and is scratching it, apply this ointment to the rash. Wait at least 6 hours before reapplying.
Dosage (how much medication to give): Route (how to give the medication): Special instructions on how to give medication: Possible Reactions or side effects: ☐ Child has received at least one dose of medication at home without reactions or side effects. Prescribing health care professional name: Phone: Pharmacy Phone: I give authorization to give medicine and to call the prescribing health care professional or pharmacy if needed
Parent/guardian name: Parent/guardian signature: Date: Medication received, returned, or disposed of:
Received from Parent/ Guardian
Date Amount Parent/Guardian Signature Child Care Provider Signature
Returned to Parent/Guardian
Date Amount Child Care Provider Signature Witness Signature
Disposed of Medicine Date Amount Child Care Provider Signature Witness Signature
Medication Administration Record 10A NCAC 09 .0803 (centers) and .1720 (family child care homes)
NC Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017
Person who gives the child the medicine completes this Medication Administration Record. Copy this page when you need more lines to record medication administration. Attach page to the Medication Administration Permission.
If an error occurs and the child requires medical attention, call 9-1-1 and/or Poison Control immediately. Child’s name:
Medication name: Date given
Time given
Dose given
Route Name of person giving medication
Signature of person giving medication
Reaction/side effect, if observed
Date Time Error or mishap while giving medication Parent/guardian notified?
Child care provider signature
Yes No
Yes No
Yes No
Allergy and Anaphylaxis Emergency Plan
Child’s name: _________________________________ Date of plan: ________________
Date of birth: ____/____/______ Age _____ Weight: _________kg
Child has allergy to _________________________________________________________ Child has asthma. Yes No (If yes, higher chance severe reaction) Child has had anaphylaxis. Yes No Child may carry medicine. Yes No Child may give him/herself medicine. Yes No (If child refuses/is unable to self-treat, an adult must give medicine) IMPORTANT REMINDER Anaphylaxis is a potentially life-threating, severe allergic reaction. If in doubt, give epinephrine. For Severe Allergy and Anaphylaxis What to look for If child has ANY of these severe symptoms after eating the food or having a sting, give epinephrine. Shortness of breath, wheezing, or coughing Skin color is pale or has a bluish color Weak pulse Fainting or dizziness Tight or hoarse throat Trouble breathing or swallowing Swelling of lips or tongue that bother breathing Vomiting or diarrhea (if severe or combined with other
symptoms) Many hives or redness over body Feeling of “doom,” confusion, altered consciousness, or
agitation
Give epinephrine! What to do 1. Inject epinephrine right away! Note time when
epinephrine was given. 2. Call 911.
Ask for ambulance with epinephrine.
Tell rescue squad when epinephrine was given. 3. Stay with child and:
Call parents and child’s doctor.
Give a second dose of epinephrine, if symptoms get worse, continue, or do not get better in 5 minutes.
Keep child lying on back. If the child vomits or has trouble breathing, keep child lying on his or her side.
4. Give other medicine, if prescribed. Do not use other medicine in place of epinephrine.
Antihistamine
Inhaler/bronchodilator
For Mild Allergic Reaction What to look for If child has had any mild symptoms, monitor child. Symptoms may include:
Itchy nose, sneezing, itchy mouth A few hives Mild stomach nausea or discomfort
Monitor child What to do Stay with child and: Watch child closely. Give antihistamine (if prescribed). Call parents and child’s doctor. If symptoms of severe allergy/anaphylaxis develop,
use epinephrine. (See “For Severe Allergy and Anaphylaxis.”)
Medicines/Doses Epinephrine, intramuscular (list type):__________________ Dose: 0.15 mg 0.30 mg (weight more than 25 kg) Antihistamine, by mouth (type and dose): ______________________________________________________________ Other (for example, inhaler/bronchodilator if child has asthma): _____________________________________________ ________________________________ ______________ _______________________________ _____________ Parent/Guardian Authorization Signature Date Physician/HCP Authorization Signature Date
© 2017 American Academy of Pediatrics. All rights reserved. Your child’s doctor will tell you to do what’s best for your child. This information should not take the place of talking with your child’s doctor. Page 1 of 2.
Attach child’s photo
� SPECIAL SITUATION: If this box is checked, child has an extremely severe allergy to an insect sting or the following food(s):______________________. Even if child has MILD symptoms after a sting or eating these foods, give epinephrine.
Allergy and Anaphylaxis Emergency Plan Child’s name: ________________________________________ Date of plan: ________________________________
Additional Instructions:
Contacts
Call 911 / Rescue squad: (___) _____-_________
Doctor: ___________________________________________________________ Phone: ( ) - .
Parent/Guardian: ____________________________________________________ Phone: (_ __) _____-_________
Parent/Guardian: ____________________________________________________ Phone: (_ __) _____-_________
Other Emergency Contacts
Name/Relationship: __________________________________________________ Phone: (__ _) _____-_________
Name/Relationship: __________________________________________________ Phone: (_ __) _____-_________
© 2017 American Academy of Pediatrics. All rights reserved. Your child’s doctor will tell you to do what’s best for your child. This information should not take the place of talking with your child’s doctor. Page 2 of 2.
1 Medical Action Plan - Asthma
10A NCAC 09 .0801 (centers) and .1721 (family child care homes)
NC Child Care Health Consultants Association, the NC Child Care Health and Safety Resource Center, and NC DHHS DCDEE Updated November 2017
Action plan’s must be completed by the child's parent or health care professional, attached to the child’s application, and updated annually. The completed action plan should be stored in the child’s file and facility’s Ready to Go File and a copy kept in the classroom. Name of person completing form: Today’s date: Child's full name: Date of birth: Parent/guardian: Phone: Primary Health Care Professional name: Phone: Primary Health Care Professional signature:
Asthma Triggers (Avoid exposure to triggers) Severity of asthma □ Carpet □ Animals □ Tobacco smoke
□ Mold □ Pollen □ Dust (mites)
□ Cockroaches □ Chemical sprays □ Strong odors
□ Changes in weather □ Illness □ Other:__________________
□ Mild intermittent □ Mild persistent □ Moderate persistent □ Severe persistent
List Allergies: Consult with a Child Care Health Consultant about this plan.
GREEN - GO Child is breathing well. Use these long-term CONTROL medicines every day to keep child in the green zone.
No cough or wheeze.
Sleeps well at night.
Plays actively.
No early warning
signs.
Medicine: How much to give: When to give: __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Medication before active play or exercise: □ None needed □ Medication _______________ Give _____ minutes before active play or exercise.
YELLOW – CAUTION Child has some problems breathing.
Keep using long-term CONTROL green zone medicines every day. Add quick-relief medicines to keep asthma from becoming worse. Parent/legal guardian contacts the Health Care Professional when quick-relief medicine is used more than twice in a week.
Coughing Wheezing May squat or
hunch over Chest tight
Waking often Poor appetite Decreased play or activity
Other early symptoms (child specific): ______________ ______________ ______________
At Home Medicine: How much to give: When to give: Albuterol _______ OR ____________
___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)
Give first dose as soon as possible. Repeat every ____ minutes for up to a total of ____ doses if needed.
If symptoms return to Green Zone:
If symptoms do not return to Green Zone within 1-2 hours:
• Take quick-relief medicine every 4 hours for ___ days.
• Change long-term control medicines to _____________________ for ___ days.
• Contact Health Care Professional for follow-up care if symptoms return.
Take quick-relief medication again. Contact Health Care Professional.
At Child Care Medicine: How much to give: When to give: Albuterol _______ OR ____________
___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)
Give first dose as soon as possible. Call parent/guardian if symptoms do not return to green zone within 15 minutes. Repeat every _____ minutes for up to a total of _____ doses if needed.
If symptoms return to Green Zone:
If symptoms do not return to Green Zone within 1 hour:
Continue quick-relief medicine every 4 hours for remainder of time in care.
Have parent/guardian pick child up and care for the child.
See page 2 for RED – DANGER: Child has severe problems with breathing.
2 Medical Action Plan - Asthma
10A NCAC 09 .0801 (centers) and .1721 (family child care homes)
NC Child Care Health Consultants Association, the NC Child Care Health and Safety Resource Center, and NC DHHS DCDEE Updated November 2017
RED – DANGER Child has severe problems with breathing.
Get help! Give quick-relief medicines until help arrives.
Severe Symptoms Getting worse
instead of better. Coughing
constantly. Cannot talk well. Cannot play or
walk. Breathing is
hard and fast, gasping. Nostrils open
wide when child breathes. Chest muscles
tight. Space between the ribs and over the chest bone suck in with each breath. Fingernails or
lips blue.
CHILD HAS SEVERE SYMPTOMS!
At Home Medicine: How much to give: When to give: Albuterol ________ OR _____________
___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)
• Give a dose immediately and call
Health Care Professional. • Repeat every ____ minutes until
medical help is obtained. • Do not leave child alone.
CALL 9-1-1 if symptoms last more than a few minutes.
At Child Care Medicine: How much to give: When to give:
Albuterol ________ OR _____________
___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)
• Give a dose immediately. • Call parent/guardian if not
previously called. • Call Health Care Professional if
unable to reach parent/guardian. • Repeat dose every ______ minutes
until medical help is available. • Do not leave child alone.
Plan reviewed by: Child Care Director/Operator name: Date:
Signature:
Child Care Health Consultant name: Date:
Signature:
Child care staff trained to care for child: #1: #2: #3:
Who will move and/or care for other children?
Who will notify the child’s parents?
Who will call and assist EMS (911) when needed?
Who will go to the hospital when needed and stay with child until parent/legal guardian assumes responsibility?
Child Care DiabetesMedical Management PlanName of Child: ________________________________________ DOB: __________ Dates Plan in Effect: ______________
Parent or guardian Name(s)/Number(s): _____________________________________________________________________
Diabetes Care Provider Name/Number: ______________________________________________________________________
Diabetes Care Provider Signature: _______________________________________________________ Date: ______________
Location of diabetes supplies at child care facility: _____________________________________________________________
Blood Glucose MonitoringTarget range for blood glucose is: � 80-180 � Other ________________________________________________________
When to check blood glucose: � before breakfast � before lunch � before dinner � before snacks
When to do extra blood glucose checks: � before exercise � after exercise � when showing signs of low blood glucose
� � when showing signs of high blood glucose � other ______________________
Insulin Plan: Please indicate which type of insulin regimen this child uses (check one):
� � Insulin Pump � Multiple Daily Injections � Fixed Insulin Doses
Specific information related to each insulin regimen/plan is included below for this child.
Type of insulin used at child care (check all that apply): � Regular � Apidra � Humalog � Novolog � NPH
� Lantus � Levemir � Mix � Other ______________
Plan A: Insulin Pump*1. Always use the insulin pump bolus
wizard: � Yes � No
If no, use Insulin:Carbohydrate Ratio and
Correction Factor dosage on Plan B.
2. Blood glucose must be checked before
the child eats and will (check one):
�� Be sent to the pump by the meter
�� Need to be entered into the pump
3. The insulin pump will calculate the
correction dose to be delivered before
the meal/snack.
4. After the meal/snack, enter the total
number of carbohydrates eaten at
that meal/snack. The insulin pump will
calculate the insulin dose for the meal.
5. Contact parent/guardian with any
concerns.
For a list of definitions of terms used in
this document, please see the Diabetes
Dictionary.
*Providers should complete Insulin:Carbohydrate ratio and Correction dosage under Plan B section for ALL pump users.
Plan B: Multiple Daily Injections1. Child will receive a fixed dose of
__________ long-acting insulin at
__________ � Yes � No
2. Follow blood glucose monitoring
plan above.
3. Use _____________ insulin for meals and snacks. Insulin dose for food is
_____ unit(s) for meals OR _____ unit(s) for every _____ grams
carbohydrate.
Give injection after the child eats.
4. If blood glucose is above target, add
correction dose to:
�� Breakfast � Snack � Lunch � Snack � Other: _____________________
Use the following correction factor
_____________ or this scale:
_____ units if BG is _____ to _____
_____ units if BG is _____ to _____
_____ units if BG is _____ to _____
_____ units if BG is _____ to _____
Only add correction dose if it has been 3 hours since the last insulin administration.
C: Fixed Insulin Doses1. Child will receive a fixed dose of long
acting insulin? � Yes � No If yes, give child _________ units of
_________ insulin at _________.
2. Insulin correction dose at child care
( _________ insulin)?
� Yes � No
3. If blood glucose is above target, add
correction dose to:
�� Breakfast � Snack � Lunch � Snack � Other: _____________________
Use the following correction factor
_____________ or the following
scale:
_____ units if BG is _____ to _____
_____ units if BG is _____ to _____
_____ units if BG is _____ to _____
_____ units if BG is _____ to _____
Only add correction dose if it has been 3 hours since the last insulin administration.
Managing Very Low Blood GlucoseHypoglycemia Plan for Blood Glucose less than ______________ mg/dL1. Give 15 grams of fast acting carbohydrate.2. Recheck blood glucose in 15 minutes.3. If still below 70 mg/dL, offer 15 grams of fast acting
carbohydrate, check again in 15 minutes.4. When the child’s blood glucose is over 70, provide 15g of
carbohydrate as snack. Do not give insulin with this snack.5. Contact the parent/guardian any time blood glucose is
less than ________ mg/dL at child care.
Usual symptoms of hypoglycemia for this child include:� Shaky � Fast heartbeat � Sweating� Anxious � Hungry � Weakness/Fatigue� Headache � Blurry vision � Irritable/Grouchy� Dizzy � Other __________________________
1. If you suspect low blood glucose, check blood glucose!2. If blood glucose is below ________, follow the plan above.3. If the child is unconscious, having a seizure (convulsion) or
unable to swallow:
the first hash mark on the syringe. Then inject into the thigh. Turn child on side as vomiting may occur.
911 (or other emergency assistance). After calling 911, contact the parents/guardian. If unable to reach parent, contact diabetes care provider.
Managing Very High Blood GlucoseHyperglycemia Plan for Blood Glucose higher than ______________ mg/dLUsual symptoms of hyperglycemia for this child include:� Extreme thirst � Very wet diapers, accidents� Hungry � Warm, dry, flushed skin � Tired or drowsy � Headache � Blurry vision � Vomiting**� Fruity breath � Rapid, shallow breathing � Abdominal pain � Unsteady walk (more than typical)**If child is vomiting, contact parents immediately
Treatment of hyperglycemia/very high blood glucose: 1. Check for ketones in the: � urine � blood (parent will provide training) 2. If ketones are moderate or large, contact parent. If
unable to reach parent, contact diabetes care provider for additional instructions.
Contact parent if ketones are trace or small: � Yes � No
insulin if the last dose of insulin was given 3 or more hours earlier. Consult the insulin plan above for instructions. If still uncertain how to manage high blood glucose, contact the parent.
4. Provide sugar free fluids as tolerated.5. You may also:�� Provide carbohydrate free snacks if hungry�� Delay exercise��
to the bathroom�� Stay with the child
Diabetes DictionaryBlood glucose - The main sugar found in the blood and the body’s main source of energy. Also called blood sugar. The blood glucose level is the amount of glucose in a given amount of blood. It is noted in milligrams in a deciliter, or mg/dL.Bolus - An extra amount of insulin taken to lower the blood glucose or cover a meal or snack.Bolus calculator – A feature of the insulin pump that uses input from a pump user to calculate the insulin dose. The user inputs the blood glucose and amount of carbohydrate to be consumed, and the pump calculates the dose that can be approved by the user. Correction Factor – The drop in blood glucose level, measured in milligrams per deciliter (mg/dl), caused by each unit of insulin taken. Also called insulin sensitivity factor. Diabetic Ketoacidosis (DKA) – An emergency condition caused by a severe lack of insulin, that results in the breakdown of body fat for energy and an accumulation of ketones in the blood and urine. Signs of DKA are nausea and vomiting, stomach pain, fruity breath odor and rapid breathing. Untreated DKA can lead to coma and death.Fixed dose regimen – Children with diabetes who use a fixed dose regimen take the same “fixed” doses of insulin at specific times each day. They may also take additional insulin to correct hyperglycemia. Glucagon – A hormone produced in the pancreas that raises blood glucose. An injectable form of glucagon, available by prescription, is used to treat severe hypoglycemia or severely low blood glucose.Hyperglycemia - Excessive blood glucose, greater than 240 mg/dL for children using and insulin pump and greater than 300 mg/dL for children on insulin injections. If untreated, the patient is at risk for diabetic ketoacidosis (DKA).Hypoglycemia - A condition that occurs when the blood glucose is lower than normal, usually less than 70 mg/dL. Signs include hunger, nervousness, shakiness, perspiration, dizziness or light-headedness, sleepiness, and confusion. If left untreated, hypoglycemia may lead to unconsciousness. Insulin - A hormone that helps the body use glucose for energy. The beta cells of the pancreas make insulin. When the body cannot make enough insulin, it is taken by injection or through use of an insulin pump.Insulin Pump - An insulin-delivering device about the size of a deck of cards that can be worn on a belt or kept in a pocket. An insulin pump connects to narrow, flexible plastic tubing that ends with a needle inserted just under the skin. Pump users program the pump to give a steady trickle or constant (basal) amount of insulin continuously throughout the day. Then, users set the pump to release bolus doses of insulin at meals and at times when blood glucose is expected to be higher. This is based on programming done by the user.
Ketones - A chemical produced when there is a shortage of insulin in the blood and the body breaks down body fat for energy. High levels of ketones can lead to diabetic ketoacidosis and coma. Multiple Daily Injection Regimen - Multiple daily insulin regimens typically include a basal, or long acting, insulin given once per day. A short acting insulin is given by injection with meals and to correct hyperglycemia, or elevated blood glucose, multiple times each day.Type 1 Diabetes - Occurs when the body’s immune system attacks the insulin-producing beta cells in the pancreas and destroys them. The pancreas then produces little or no insulin. Type 1 diabetes develops most often in young people but can appear in adults. It is one of the most common chronic diseases diagnosed in childhood.
_____________________________________________________________________Physician Signature
Nombre ____________________________________________________________Fecha de nacimiento: ____________________
Alérgico a: _________________________________________________________________________________________________
Peso: __________________ kilos. Asma: [ ] Sí (Riesgo más alto de reacción grave) [ ] No
COLOQUE UNA
FOTOGRAFÍA AQUÍ
1. Se pueden administrar antihistamínicos, con prescripción médica.
2. Quédese junto a la persona; comuníquese con los contactos de emergencia.
3. Observe atentamente los posibles cambios. Si los síntomas empeoran, administre epinefrina.
FIRMA DE AUTORIZACIÓN DEL PACIENTE O PADRE/TUTOR FECHA FIRMA DE AUTORIZACIÓN DEL MÉDICO O PROFESIONAL DE SALUD INTERVINIENTE FECHA
FORMULARIO SUMINISTRADO POR CORTESÍA DE FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 3/2017
1. INYECTE EPINEFRINA DE INMEDIATO2. Llame al 911. Avise al operador telefónico que el paciente tiene anafilaxia
y puede necesitar epinefrina cuando llegue el equipo de emergencia.• Considerelaadministracióndeotrosmedicamentosademásdela
epinefrina: -Antihistamínico -Inhalador (broncodilatador) en caso de respiración sibilante• Mantenga al paciente en posición horizontal, con las piernas
en alto y abrigado. Si tiene dificultades para respirar o vómitos, manténgalo sentado o tendido sobre un costado.
• Si los síntomas no mejoran o vuelven a aparecer, puede administrar otras dosis adicionales de epinefrina a partir de los 5 minutos de la administración de la última dosis.
• Comuníquese con los contactos de emergencia.• Lleve al paciente a la sala de emergencias, aunque los síntomas
hayan desaparecido. (El paciente debe permanecer en la guardia médica durante por lo menos 4 horas porque los síntomas pueden reaparecer).
CORAZÓN Tez azulada o
pálida,desmayo,pulso débil,
mareo
BOCA Hinchazón
significativa de la lengua o los
labios
O UNA COMBINACIÓN de los síntomas de las distintas
áreas
PULMÓN Falta de aire,
sibilancia,mucha tos
PIEL Urticaria
extendida en las distintas partes
del cuerpo, enrojecimiento generalizado
INTESTINOS Vómitos
reiterados,diarrea grave
NARIZ Picazón o
moqueo nasal, estornudos
BOCA Picazón bucal
PIEL Algunasronchas,
picazón leve
INTESTINO Náuseasleveso
malestarGARGANTA
Ronquera u oclusión,
dificultad para tragar o respirar
OTRO Sensación de que
va a pasar algo malo, ansiedad,
confusión.
Marcadeepinefrinaofármacogenérico: ________________________
Dosis de epinefrina: [ ] 0,15 mg IM [ ] 0,3 mg IM
Marcadeantihistamínicoofármacogenérico: ____________________
Dosis de antihistamínico: _____________________________________
Otros (por ejemplo, broncodilatador en caso de sibilancia): ________
____________________________________________________________
MEDICAMENTOS/DOSIS
SÍNTOMAS GRAVES SÍNTOMAS LEVES
EN CASO DE SÍNTOMAS LEVES EN MÁS DE UN ÁREA DEL CUERPO, ADMINISTRE EPINEFRINA.
EN CASO DE SÍNTOMAS LEVES EN UN ÁREA ÚNICA SIGA ESTAS INSTRUCCIONES:
ANTE CUALQUIERA DE LOS SIGUIENTES:
NOTA: No recurra a antihistamínicos ni inhaladores (broncodilatadores) para tratar una reacción grave. UTILICE EPINEFRINA.
Extremadamente reactivo a los siguientes alérgenos: ___________________________________________________
POR LO TANTO:[ ] Si esta opción está marcada y es PROBABLE que se ha ingerido el alérgeno, administre epinefrina de inmediato ante CUALQUIERA de estos síntomas.
[ ] Si esta opción está marcada y es SEGURO que se ha ingerido el alérgeno, administre epinefrina de inmediato aunque no se observe ningún síntoma.
PLAN DE ATENCIÓN DE EMERGENCIAS DE ALERGIAS ALIMENTARIAS Y ANAFILAXIA
CÓMO UTILIZAR LA INYECCIÓN DE EPINEFRINA IMPAX (GENÉRICO AUTORIZADO DE ADRENACLICK®), USP, AUTOINYECTOR, LABORATORIOS IMPAX 1. Retire del autoinyector de epinefrina de su estuche protector. 2. Saquelasdostapasdeextremoazul.Ahorapodráverunapuntaroja.3. Sujete el autoinyector firmemente con el puño con la punta roja apuntando hacia abajo. 4. Coloquelapuntarojacontralaparteexteriormediadelmusloenunángulode90º,enposiciónperpendicular
al muslo. 5. Oprima y sostenga con firmeza durante aproximadamente 10 segundos. 6. Retireeldispositivoymasajeeeláreadurante10segundos.7. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.
CÓMO UTILIZAR LA INYECCIÓN DE EPINEFRINA (FÁRMACO GENÉRICO AUTORIZADO DE EPIPEN®), USP (AUTOINYECTOR), MYLAN 1. Retire el autoinyector de epinefrina del tubo transparente. 2. Sujete el autoinyector firmemente con el puño con la punta naranja (el extremo de la aguja) apuntando
hacia abajo.3. Con la otra mano, retire el protector de seguridad azul tirando firmemente hacia arriba. i4. Gire y oprima con firmeza el autoinyector contra la parte exterior media del muslo hasta que haga clic. 5. Sostenga firmemente en el lugar durante 3 segundos (cuente lentamente 1, 2, 3). 6. Retireeldispositivoymasajeeeláreadurante10segundos.7. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.
CÓMO USAR EL AUTOINYECTOR DE EPINEFRINA EPIPEN® Y EPIPEN JR®, MYLAN1. Retire el autoinyector Epipen® o EpiPen Jr® del tubo transparente.2. Sujete el autoinyector firmemente con el puño con la punta naranja (el extremo de la aguja) apuntando
hacia abajo.3. Con la otra mano, retire el protector de seguridad azul tirando firmemente hacia arriba.4. Gire y oprima con firmeza el autoinyector contra la parte exterior media del muslo hasta que haga clic.5. Sostenga firmemente en el lugar durante 3 segundos (cuente lentamente 1, 2, 3).6. Retireeldispositivoymasajeeeláreadurante10segundos.
7. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.
INSTRUCCIONES/INFORMACIÓN ADICIONAL (la persona puede llevar epinefrina, el paciente puede autoadministrarse la medicación, etc.):
FORMULARIO SUMINISTRADO POR CORTESÍA DE FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 3/2017
CONTACTOS DE EMERGENCIA – LLAME AL 911EQUIPO DE RESCATE: __________________________________________________________________
MÉDICO: _________________________________________________ TELÉFONO: ________________
PADRE O TUTOR: _________________________________________ TELÉFONO: ________________
OTROS CONTACTOS DE EMERGENCIA
NOMBRE/RELACIÓN: ___________________________________________________________________
TELÉFONO: ___________________________________________________________________________
NOMBRE/RELACIÓN: ___________________________________________________________________
TELÉFONO: ____________________________________________________________________________
Trate a la persona antes de llamar a los contactos de emergencia. Las primeras señales de una reacción pueden ser leves, pero los síntomas pueden agravarse con rapidez.
INFORMACIÓN DE ADMINISTRACIÓN Y SEGURIDAD PARA TODOS LOS AUTOINYECTORES:1. Nocoloqueeldedopulgar,losdemásdedosolamanosobrelapuntadelautoinyectorniapliquelainyecciónfueradelaparteexterior
mediadelmuslo.Encasodeinyecciónaccidental,diríjaseinmediatamentealasaladeemergenciasmáscercana.2. Si administra el medicamento a un niño pequeño, sostenga su pierna firmemente antes y durante la aplicación para evitar posibles
lesiones.3. Si es necesario, la epinefrina se puede aplicar a través de la ropa.
4. Llameal911inmediatamenteluegodeaplicarlainyección.
CÓMO UTILIZAR AUVI-Q® (INYECCIÓN DE EPINEFRINA, USP), KALEO1. Retire AUVI-Q del estuche externo.2. Saque la tapa de seguridad roja.3. Coloque el extremo negro de AUVI-Q® contra la parte exterior media del muslo.4. Oprima firmemente, y mantenga presionado durante 5 segundos.
5. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.
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PLAN DE ATENCIÓN DE EMERGENCIAS DE ALERGIAS ALIMENTARIAS Y ANAFILAXIA
Name: _________________________________________________________________________ D.O.B.: ____________________
Allergy to: __________________________________________________________________________________________________
Weight: ________________ lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No
PLACE PICTURE
HERE
1. Antihistamines may be given, if ordered by a healthcare provider.
2. Stay with the person; alert emergency contacts.
3. Watch closely for changes. If symptoms worsen, give epinephrine.
PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017
1. INJECT EPINEPHRINE IMMEDIATELY.2. Call 911. Tell emergency dispatcher the person is having
anaphylaxis and may need epinephrine when emergency responders arrive.
• Consider giving additional medications following epinephrine:
» Antihistamine » Inhaler (bronchodilator) if wheezing
• Lay the person flat, raise legs and keep warm. If breathing is difficult or they are vomiting, let them sit up or lie on their side.
• If symptoms do not improve, or symptoms return, more doses of epinephrine can be given about 5 minutes or more after the last dose.
• Alert emergency contacts.
• Transport patient to ER, even if symptoms resolve. Patient should remain in ER for at least 4 hours because symptoms may return.
HEART Pale or bluish
skin, faintness, weak pulse, dizziness
MOUTH Significant
swelling of the tongue or lips
OR A COMBINATION of symptoms from different body areas.
LUNG Shortness of
breath, wheezing, repetitive cough
SKIN Many hives over body, widespread
redness
GUT Repetitive
vomiting, severe diarrhea
NOSE Itchy or
runny nose, sneezing
MOUTH Itchy mouth
SKIN A few hives,
mild itch
GUT Mild
nausea or discomfort
THROAT Tight or hoarse throat, trouble breathing or swallowing
OTHER Feeling
something bad is about to happen, anxiety, confusion
Epinephrine Brand or Generic: ________________________________
Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM
Antihistamine Brand or Generic: _______________________________
Antihistamine Dose: __________________________________________
Other (e.g., inhaler-bronchodilator if wheezing): __________________
____________________________________________________________
MEDICATIONS/DOSES
SEVERE SYMPTOMS MILD SYMPTOMS
FOR MILD SYMPTOMS FROM MORE THAN ONE SYSTEM AREA, GIVE EPINEPHRINE.
FOR MILD SYMPTOMS FROM A SINGLE SYSTEM AREA, FOLLOW THE DIRECTIONS BELOW:
FOR ANY OF THE FOLLOWING:
NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.
Extremely reactive to the following allergens: _________________________________________________________
THEREFORE:[ ] If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.
[ ] If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.
HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK®), USP AUTO-INJECTOR, IMPAX LABORATORIES 1. Remove epinephrine auto-injector from its protective carrying case.2. Pull off both blue end caps: you will now see a red tip.3. Grasp the auto-injector in your fist with the red tip pointing downward.4. Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh.5. Press down hard and hold firmly against the thigh for approximately 10 seconds. 6. Remove and massage the area for 10 seconds.7. Call 911 and get emergency medical help right away.
HOW TO USE EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF EPIPEN®), USP AUTO-INJECTOR, MYLAN 1. Remove the epinephrine auto-injector from the clear carrier tube.2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up.4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. 5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).6. Remove and massage the injection area for 10 seconds.7. Call 911 and get emergency medical help right away.
HOW TO USE EPIPEN® AND EPIPEN JR® (EPINEPHRINE) AUTO-INJECTOR, MYLAN1. Remove the EpiPen® or EpiPen Jr® Auto-Injector from the clear carrier tube.2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up.4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).6. Remove and massage the injection area for 10 seconds.7. Call 911 and get emergency medical help right away.
OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017
EMERGENCY CONTACTS — CALL 911RESCUE SQUAD: ______________________________________________________________________
DOCTOR: _________________________________________________ PHONE: ____________________
PARENT/GUARDIAN: ______________________________________ PHONE: ____________________
OTHER EMERGENCY CONTACTS
NAME/RELATIONSHIP: __________________________________________________________________
PHONE: _______________________________________________________________________________
NAME/RELATIONSHIP: __________________________________________________________________
PHONE: _______________________________________________________________________________
Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.
ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:1. Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer
thigh. In case of accidental injection, go immediately to the nearest emergency room.2. If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.3. Epinephrine can be injected through clothing if needed.4. Call 911 immediately after injection.
HOW TO USE AUVI-Q® (EPINEPHRINE INJECTION, USP), KALEO1. Remove Auvi-Q from the outer case.2. Pull off red safety guard.3. Place black end of Auvi-Q against the middle of the outer thigh.4. Press firmly, and hold in place for 5 seconds. 5. Call 911 and get emergency medical help right away.
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1 Child Medical Action Plan
The North Carolina Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017
10A NCAC 09 .0801(b) [Centers] and .1721(a)(4) [Family Child Care Homes]
If a child has health care needs that require specialized health services, the child's parent or a health care professional should complete a medical action plan and attach it to the child’s application. The plan must be updated annually and stored in the child’s file and facility’s Ready to Go File. A copy should be kept in the classroom.
Children with asthma, diabetes, seizes, or allergies should have medical action plans specific to those conditions. Name of person completing form: Today’s date:
Child’s full name: Date of birth:
Parent’s/guardian’s name: Phone:
Primary health care professional: Phone:
Specialist/therapist: Type: Phone:
Specialist/therapist: Type: Phone:
Diagnosis(es):
Allergies (food, medication, environmental, insects, or other):
Medication(s) Complete a Medication Administration Permission Form if medications listed below are to be provided by the child care. Complete page three if child has more than two medications.
Medication name: Daily medication taken at child care
Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Medication name: Daily medication taken at child care
Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Accommodation(s) Describe any accommodation(s) the child needs in daily activities and why.
Diet or Feeding:
Classroom Activities:
Naptime/Sleeping:
Toileting:
Outdoors or Field Trips:
Transportation:
Other/Comments:
2 Child Medical Action Plan
The North Carolina Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017
Equipment/Medical Supplies
Emergency Care
Suggested Special Training for Staff
If completed by a health care professional:
Parent notes
Parent/Guardian Signature: Date:
1.
2.
3.
4.
Call parents/guardians if the following symptoms are present:
Call 911 (emergency medical services) if the following symptoms are present, and contact the parents/guardians:
Take these measures while waiting for parents or medical help to arrive:
Health Care Professional Signature: Date:
3 Child Medical Action Plan
The North Carolina Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017
Medication name: Daily medication
taken at child care Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Medication name: Daily medication taken at child care
Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Medication name: Daily medication taken at child care
Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Medication name: Daily medication taken at child care
Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Medication name: Daily medication taken at child care
Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Medication name: Daily medication taken at child care
Daily medication taken at home
Emergency medication
Dosage: Time/frequency: Route:
Special instructions: Side effects: Reason prescribed:
Seizure Action Plan
Copyright 2014 Epilepsy Foundation of America, Inc. ®
This student is being treated for a seizure disorder. The information below should assist you if a seizure occurs during school hours.
Student’s Name Date of Birth
Parent/Guardian Phone Cell
Other Emergency Contact Phone Cell
Treating Physician Phone
Significant Medical History
Seizure Information
Seizure Type Length Frequency Description
Seizure triggers or warning signs: Students’s response after a seizure:
Basic First Aid Care & Comfort Basic Seizure First Aid
Please describe basic first aid procedures: • Stay calm & track time• Keep child safe• Do not restrain• Do not put anything in mouth• Stay with child until fully conscious• Record seizure in logFor tonic-clonic seizure:• Protect head• Keep airway open/watch breathing• Turn child on side
Does student need to leave the classroom after a seizure? p Yes p NoIf YES, describe process for returning student to classroom:
Emergency Response A seizure is generally considered an emergency when:• Convulsive (tonic-clonic) seizure lasts
longer than 5 minutes• Student has repeat seizures without
regaining consciousness• Student is injured or has diabetes• Student has a first-time seizure• Student has breathing difficulties• Student has a seizure in water
A “seizure emergency” for this student is defined as:
Seizure Emergency Protocol (Check all that apply and clarify below)p Contact school nurse at _________________________p Call 911 for transport to __________________________p Notify parent or emergency contactp Administer emergency medications as indicated belowp Notify doctorp Other________________________________________
Treatment Protocol During School Hours (include daily and emergency medications)
Emerg. Med. Medication Dosage & Time of Day Given Common Side Effects & Special Instructions
Does student have a Vagus Nerve Stimulator? p Yes p No If YES, describe magnet use:
Special Considerations and Precautions (regarding school activities, sports, trips, etc.)
Describe any special considerations or precautions:
Physician Signature_____________________________________________________________ Date___________________
Parent/Guardian/Signature________________________________________________________ Date___________________