Disease Specific ECP | IHP | 504 |Diabetes Addendum | Flow Sheets

Sample Resources Below should be reviewed and approved by the School Medical Director and/or BOE prior to use.

Allergy|Anaphylaxis Care Plans

AAP Allergy and Anaphylaxis Emergency Plan (Updated 3/2019)

FARE Food Allergy ECP in both English and Spanish (5/2018)

Asthma Care Plans and Action Plans (AAP)

Asthma Action Plan-NYSDOH (5/2017)

Sample Emergency Care Plan for Unlicensed School Personnel: ASTHMA  (3/2017) -Provides easy to understand information for unlicensed school staff to assist and respond to an asthma emergency

Sample Letter to Families about Metered Dose Inhalers, Spacers and Nebulizers- Provides information on why a MDI and Spacer is preferable over a nebulizer during the COVID Pandemic (NYSCSH 9/2/20).

Sample Provider and Parent Guardian Permission for the use of School Provided Spacer/Valved Holding Chamber
Provides schools the opportunity to provide a back-up spacer in the event that the student's is not available. (7/7/20)

Diabetes Medical Management Plans (DMMPs)|Addendum to Allow  HCP Provide Criteria for Parents Input on Insulin Dose

DMMP from the Diabetes in Children pages 82-86 provided by NYSDOH. (11/2018)

Effective Diabetes tools for a successful management of diabetic management. Here you will find a sample Diabetes Medical Management Plan, a sample template for an Individualized Health Care Plan, and sample Emergency Care Plans for Hypoglycemia and Hyperglycemia.

Additional FAQs, as to who can carry out a Diabetic Emergency plan within a school system, how long do they last, etc, please visit, The National Institute of Diabetes and Digestive and Kidney Diseases.

 DMMP Addendum: Role of Parents/Guardians in Adjustment of Insulin Dose-Allows the HCP to provide criteria by which the parent may be consulted in adjusting insulin doses administered by a nurse during school hours and at school-sponsored events, to the extent reasonably practicable. 5/2017 Note: HCP orders only allow the parent to provide proposed adjustments or dosages and require the health care professional to make the ultimate decision after exercising his/her professional judgment. 

Math Calculation Checker Worksheet for Insulin Deviation-This worksheet may be used to verify that math calculations performed by the RN are correct. (9/2017)

Diabetes Hypoglycemia|Hyperglycemia Plans

Hypo and Hyperglycemia Chart for School Staff - Excerpted from NYSDOH Diabetes in Children with the permission of the NYSDOH. (1/2016)

Hypoglycemia Sample Emergency Care Plan (NYSCSH, 10/4/17)
Hyperglycemia Sample Emergency Care Plan (NYSCSH 10/4/17)

Glucagon Training Documentation Form for School Personnel- Documents understanding and skills attainment for staff voluntarily administering glucagon for students with patient-specific orders. This form is also available with the PPT training program on the NYSCSH Glucagon page. 

Diabetes Sample 504 Plans

Model 504 Plan from the American Diabetes Association -(PDF 07/24/12)

School Advisory Kit for Schools (JDRF) contains information on Section 504, Legal rights of the child  Common 504 Plan questions, and references. (JDRF, 2014)

Generic Sample Care Plans and Other Emergency Documentation for Students and Staff

Sample Generic Emergency Care Plan for Unlicensed School Personnel (5/16)=Information for unlicensed school staff to assist with emergency health issues 

Special Health Care Needs Record - May be used to document student health concerns, provider|parent permissions, medications, and ECP (9/12)

Sample Emergency Care Flow Sheet - School Nurse documentation form

Sample Emergency Care Flow Sheet for Staff - School Nurse documentation form 10/2017

Sample Faculty/Staff Emergency Contact Information - Documents emergency contact information for staff

Sample Individual Health Care Plan (8/18)

Seizure Sample Care Plans | 504 Plans | Interview Questionnaire for Seizure History

Diastat®/Seizure Preparedness Plan - Links to Diastat™ website. Provides resources and information for creating a seizure emergency plan.

Seizure Emergency Care Plan - Provides information for emergency management in both English and Spanish (Epilepsy Foundation, 2010).

Seizure ECP- Customizable template for the HCP to document type of seizure and treatment plan. Separate medication order would be needed. (NYSCSH, Revised 9/2012).

Seizure ECP with Medication Information - Customizable template for HCP to document response plan for seizures. Includes area for medication and Vagal Nerve Stimulator orders (NYSCH. 9/2012)

Parent Interview Questionnaire for Seizure History - Documents seizure history medications and current understanding of the condition. (NYSCSH, 6/2012) 

Seizure Observation / Recording Form which can be used to record seizures. They include calendars, diaries, and logs from Epilepsy/com

504 Plan - Sample plan from Epilepsy.com

Sample Students With Special Health Care Needs Record
May be used to record students' health care concern, medication and emergency care plan status (2/2021).

Page updated 2/20/21