Seizure Action Plan and Emergency Medication Administration Form

Documents a student's seizure triggers, individualized response steps, emergency contacts, and rescue-medication administration instructions for school use.

Submission Notice

• Student full name
• Date of birth
  Collect only if needed to correctly identify the student and avoid duplicate records.
• School name
• Grade or homeroom
• Submitted by

Student and Care Team Information

• Primary parent/guardian name
• Primary phone number
• Secondary emergency contact name
• Secondary emergency contact phone
• Healthcare provider name
• Healthcare provider phone

Seizure History and Triggers

• Diagnosis or seizure condition
  Use a general description only; do not include unnecessary medical detail.
• Typical seizure types
• Known seizure triggers
• Usual warning signs or aura
• Typical seizure duration in minutes

Seizure Response Plan

• Immediate response steps for staff
  Include positioning, airway protection, timekeeping, supervision, and when to clear the area.
• How should staff protect the student from injury?
• When should staff call 911?
  List the exact emergency conditions, such as seizure duration, breathing concerns, injury, or repeated seizures.
• Post-seizure care instructions
  Include rest, reorientation, hydration, privacy, and return-to-class guidance.
• Activity restrictions after a seizure

Rescue Medication Authorization

• Is rescue medication prescribed for seizure emergencies?
• Medication name
• Administration route
• Dose and administration instructions
  Include dose, timing, and any device-specific instructions from the prescriber.
• When should the medication be given?
• Medication storage location at school

Consent, Accessibility, and Acknowledgment

• Consent to share this plan with designated school staff on a need-to-know basis
• Reasonable accommodations or accessibility needs
  Include any ADA-related supports needed for safe response, communication, or recovery.
• Parent/guardian acknowledgment
  Signature may be collected if your process requires formal authorization.
• Plan review date
  Use this to schedule periodic review and update the audit trail when the plan changes.