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: _______________ |