Student Name: Health Condition:

Date of Birth: mm/dd/yy School: Grade: Routine medications (at home and school)

Transportation: Bus # __________ Car Walk

Other health problems: Preferred Hospital:

Location where emergency medication(s) is/are stored:

N/A Health Office Backpack On Person Locker # __________ Other ________________

HEALTH CARE PROVIDER—Tube Feeding Orders and Instructions

Early Signs and Symptoms & Special Instructions

MUKWONAGO AREA SCHOOL DISTRICT—HEALTH SERVICES DISTRICT NURSE PHONE: 262-363-6292 X27515

G-TUBE HEALTH CARE PLAN for

Date Received ___________

Date Revised ____________

Description of Health Condition:

Please complete specific Health Care Plans for: Asthma / Diabetes / Seizure Disorder / Severe Allergic Reaction See Health Assistant or District website for forms

Signs and Symptoms Special Instructions Contact Parent

YES NO

YES NO

EMERGENCY—Signs and Symptoms

Call 911 for ANY of the above EMERGENCY signs and symptoms

Remain calm!

Remain with student and send another student or staff member for help.

Clear room of other students and provide as much privacy as possible.

Call parent/guardian to inform them that 911 has been called

Other special instructions:

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Formula or Equivalent: Volume:

Route: Method of Delivery:

Preparation and Feeding Instructions:

Frequency: Possible Side Effects:

Medication Orders:

Health Care Provider Signature: Date:

Phone Number: (xxx-xxx-xxxx) Fax: (xxx-xxx-xxxx)

I approve this G-Tube Health Care Plan for my child.

I request this feeding and/or medication to be given as ordered by the Health Care Provider.

I give consent to share information about my child’s health condition with the district nurse, health assistant, teachers, principal, office staff, guidance, bus driver/transportation, cafeteria workers, playground staff, and emergency staff on a “need to know basis”.

I give Health Services Staff permission to communicate with the medical office about this care plan / medication. I understand the feeding and/or medication(s) will not necessarily be given by the district nurse, but may be given by the health assistant or designated trained staff.

Parent/guardian must provide medication/equipment required to administer medication, feeding or provide special medical care.

All medication supplied must come in its original pharmacy-labeled container; and the container specifies the student’s name, name of prescriber, the name of medication, the dose, the effective date, and the directions for administration.

Any changes in feeding and/or medication require a new written authorization and corresponding change in the prescription label.

I understand that the medication maintained in the health room is not available after school hours, and that I need to provide additional rescue medications for my child when involved in sports/activities after school hours. Parent/Guardian Signature ___________________________________________________________________ Date _________________________

District Nurse Signature ______________________________________________________________________ Date Reviewed _________________

Fax Numbers: Big Bend 262-662-1309 Clarendon 262-363-6289 Eagleville 262-594-5495 Prairie View 262-392-6312 Rolling Hills 262-363-6343 Section 262-363-6341 Park View 262-363-6320 Mukwonago High 262-363-6239

District Nurse Phone: 262-363-6292 x27515 Fax: 262-363-6320

1. Relationship: Day Phone: xxx-xxx-xxxx Cell Phone: xxx-xxx-xxxx

2. Relationship; Day Phone: xxx-xxx-xxxx Cell Phone: xxx-xxx-xxxx

3. Relationship: Day Phone: xxx-xxx-xxxx Cell Phone: xxx-xxx-xxxx

4. Relationship: Day Phone: xxx-xxx-xxxx Cell Phone: xxx-xxx-xxxx

Individual Considerations Activity Limitations / Restrictions:

Special Dietary Needs:

Dislodged G-Tube NOT an Emergency 1. Put gloves on

2. Cover G-tube site with a clean gauze/dressing/Band-Aid 3. Save the G-tube, wrap in paper towel 4. Call Parent– may come to school to replace G-tube 5. Call District Nurse– report incident and response 6. Call Doctor– if unable to contact parent/emergency contact

Field Trip Procedures

Staff members on trip must be trained regarding __________________________ use and student health care plan (plan must be taken).

Other (specify):

Bus—Transportation should be alerted to student’s ______________________ condition Yes No

Student will sit at front of the bus: Yes No Other consideration:

EMERGENCY CONTACTS

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Student Name ___________________________________

G-TUBE HEALTH CARE PLAN for