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

Allergy|Anaphylaxis Sample Care Plans

AAP Allergy and Anaphylaxis Emergency Plan (Updated 3/2017)

FARE Food Allergy ECP in both English and Spanish (4/2017)

 Asthma Sample Care Plans and Action Plans (AAP)

Asthma Action Plan-NYC (10/2013)

Asthma Action Plan-NYSDOH (5/2017)

Sample Emergency Care Plan for Unlicensed School Personnel: ASTHMA  (3/2017) 
Information for unlicensed school staff to assist with emergency health issues

Sample Provider and Parent Guardian Permission for Use of School Provided Spacer/Valved Holding Chamber (8/2018)

Diabetes Medical Managment Plans| Addendum-Role of Parents In Insulin Dose|IHP Hypo/Hyperglycemia|504 Plan Resources

DMMPs/DMMP Addendum

Diabetes in Children - A Resource Guide for Families and SchoolsContains sample DDMP, ECP, IHP and 504 plans per instructions on the order form.

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

Diabetes Medical Management Plan - American Diabetes Association has partnered with the National Diabetes Education Program to create a DMMP template that can be customized for every student.

Diabetes Medication Administration Form - NYC Office of School Health 2017-2018 School Year

Diabetes Medical Management Plan 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 

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)

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)

Sample 504 Plans

Model 504 Plan from the American Diabetes Association (7/2012)

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 record students' health concern, provider and 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.

Epilepsy Foundation Emergency Care Plan - Provides information for emergency management in both English and Spanish.

Seizure ECP- Customizable template for health care provider to document type of seizure and treatment plan.  Separate medication order would be needed.  (Revised 9/2012).

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

NYSCSH Parent Interview Questionnaire for Seizure History - Documents students seizure history medications and students current understanding of the condition. (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

Updated 11/7/18