5141.25 FORM 6 Individualized Healthcare Plan (Elementary)
| | | INDIVIDUALIZED HEALTHCARE PLAN (Elementary) | ||||||||||||||||||||
| Student Name: ______________________________ Birth Date: ______________ Grade: __________ Teacher: _____________________________ | ||||||||||||||||||||||
| Plan effective from 2006 to 2007 | ||||||||||||||||||||||
| ASSESSMENT DATE/NURSE | FUNCTIONAL HEALTH CONCERN | STUDENT OBJECTIVE(S) | INTERVENTIONS | EVALUATION | ||||||||||||||||||
| Risk of anaphylactic reaction (life-threatening allergic response) related to the ingestion or inhalation of peanuts and/or tree nuts (protein component) | Student will cooperate with staff 100% of the time by following school, classroom and IHCP rules in order to remain free of allergic reactions while in school. | Parents will: | [Enter documentation method or date(s) accomplished for all applicable inteventions] | |||||||||||||||||||
| ² | inform school nurse and teacher of food allergy | |||||||||||||||||||||
| ² | provide a physician's order and medication for medical intervention | |||||||||||||||||||||
| ² | inform school nurse of any changes in health status as relates to food allergy and treatment | |||||||||||||||||||||
| ² | educate student in the self-management of his/her food allergies appropriate for his/her age level | |||||||||||||||||||||
| Risk of severe allergic reaction to the ingestion or inhalation of [add other allergens here if applicable, or delete] | If student suspects that he/she has ingested (fill in food allergens), student will immediately notify staff who will implement the IECP according to the allergen-specific plan. | |||||||||||||||||||||
| ² | provide emergency contact information | |||||||||||||||||||||
| ² | meet with school nurse to develop a prevention plan | |||||||||||||||||||||
| ² | provide safe snacks/treats for student to keep in school and, if desired, a list of appropriate foods for student to have at snack | |||||||||||||||||||||
| Student has an | Nurse will: | |||||||||||||||||||||
| Individualized Emergency | Student will cooperate with staff members 100% of the time if they need to implement the IECP. | ² | meet with parents and teacher to develop a prevention plan | |||||||||||||||||||
| Care Plan (IECP) | ||||||||||||||||||||||
| ² | post "peanut/nut free" sign outside of classroom | |||||||||||||||||||||
| ² | work with teacher to eliminate the use of peanuts/tree nuts in classroom snacks, curriculum, educational tools, classroom parties, foreign language projects, and arts and crafts projects | |||||||||||||||||||||
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| ² | educate school staff who interact with student regarding food allergy, allergic reaction symptoms, recognizing signs and symptoms of anaphylaxis, and prevention and treatment plans | |||||||||||||||||||||
| ² | train school staff in EpiPen administration, as appropriate | |||||||||||||||||||||
| ² | develop and disseminate emergency care plan for student | |||||||||||||||||||||
| ² | review cleaning/care of nut/peanut free table in cafeteria with maintenance and cafeteria staff | |||||||||||||||||||||
| | INDIVIDUALIZED HEALTHCARE PLAN (Elementary) | |||||||||||||||||||||
| Student Name: ______________________________ Birth Date: ______________ Grade: __________ Teacher: _____________________________ | ||||||||||||||||||||||
| Plan effective from 2006 to 2007 | ||||||||||||||||||||||
| ASSESSMENT DATE/NURSE | FUNCTIONAL HEALTH CONCERN | STUDENT OBJECTIVE(S) | INTERVENTIONS | EVALUATION | ||||||||||||||||||
| Teacher/classroom staff will: | ||||||||||||||||||||||
| ² | eliminate the use of nuts/peanuts in classroom snacks, educational tools, and arts and crafts projects. | |||||||||||||||||||||
| ² | be trained in the administratin of EpiPen, as appropriate | |||||||||||||||||||||
| ² | consult in advance of field trips with the school nurse and parents | |||||||||||||||||||||
| ² | [for food allergens other than peanut/nut] notify parents in advance regarding curriculum/projects that may contain [add these food allergens] | |||||||||||||||||||||
| ² | follow the emergency care plan if student has a reaction | |||||||||||||||||||||
| Student will: | ||||||||||||||||||||||
| ² | not eat any foods except those that come from home or have been approved by the parent | |||||||||||||||||||||
| ² | inform teacher/staff if he/she is not feeling well, for any reason, but expecially if he/she thinks he/she may be having an allergic reaction | |||||||||||||||||||||
| School Nurse: _________________________________________ Date: _______________ | ||||||||||||||||||||||
| Review by: Parent: _________________________ Date: _______________ Student: _________________________ Date: _______________ | ||||||||||||||||||||||