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Run: Seizure Action Plan and Emergency Medication Administration Form

A school seizure action plan and emergency medication form for documenting triggers, response steps, rescue-medication instructions, and emergency contacts. ...

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Submission Notice

Student full name (required)

Date of birth

Collect only if needed to correctly identify the student and avoid duplicate records.

School name (required)

Grade or homeroom

Submitted by (required)

Student and Care Team Information

Primary parent/guardian name (required)

Primary phone number (required)

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 (required)

Known seizure triggers

Usual warning signs or aura

Typical seizure duration in minutes

Seizure Response Plan

Immediate response steps for staff (required)

Include positioning, airway protection, timekeeping, supervision, and when to clear the area.

How should staff protect the student from injury? (required)

When should staff call 911? (required)

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? (required)

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 (required)

Yes No N/A

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.

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Email (required)

Your name (optional)

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