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Run: Student Asthma Action Plan and Inhaler Self-Carry Authorization

This Student Asthma Action Plan and Inhaler Self-Carry Authorization collects the physician plan, emergency steps, and school permissions needed to support a...

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Submission Notice

Consent to collect and use this health information for school health and emergency response purposes (required)

By checking this box, the parent/guardian authorizes the school to collect and use the student's asthma-related health information for care coordination, emergency response, and recordkeeping.

Yes No N/A

Submission type (required)

Does the student have a diagnosed asthma condition? (required)

School year (required)

Student Information

Student full name (required)

Date of birth

Collect only if needed to match the student record.

Grade level (required)

School name (required)

Student ID

Optional identifier if your school uses one.

Parent or Guardian Information

Parent/guardian name (required)

Relationship to student (required)

Primary phone number (required)

Email address

Preferred contact method (required)

Physician Asthma Action Plan

Physician or licensed prescriber name (required)

Clinic or practice name

Office phone number

Known asthma triggers

Daily controller medication instructions

Include only if the student takes a controller medication at school or needs school awareness of the schedule.

Green zone instructions (required)

Describe the student's usual condition and any daily medication or activity guidance.

Yellow zone instructions (required)

Describe symptoms, peak flow guidance if used, and when to give rescue medication.

Red zone instructions (required)

Describe severe symptoms and the steps staff should take immediately, including when to call emergency services.

Inhaler and Self-Carry Authorization

Rescue inhaler medication name (required)

Medication strength

Dose and administration instructions (required)

Include number of puffs, timing, and any spacer instructions.

May the student self-carry the inhaler? (required)

May the student self-administer the inhaler? (required)

Is a backup inhaler stored at school?

Backup inhaler storage location

Emergency Contacts and Authorizations

Emergency contact name (required)

Emergency contact phone (required)

Authorize school staff to call 911 if severe symptoms occur (required)

This authorization allows staff to seek emergency help if the student has severe breathing difficulty, blue lips, loss of consciousness, or other red zone symptoms.

Yes No N/A

Authorize sharing this plan with school staff who need to know (required)

The plan will be shared only with staff involved in the student's care, safety, or supervision.

Yes No N/A

Signatures and Verification

Parent/guardian signature (required)

Parent/guardian signed date (required)

Physician or licensed prescriber signature

Required if your school or district requires clinician verification.

Physician signed date

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Email (required)

Your name (optional)

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