EMERGENCY CARE PLAN
Policy: This form must be completed at orientation with parent/guardian. All staff must review and initial at least twice a year. Attach the Emergency Care Plan to the Child Information Record in the classroom and on the bus.
Today’s Date:______Center:______Child:______DOB:______
Parent/Guardian: ______Phone #:______
Emergency Contact: ______Phone #:______
Primary Health Care Provider: ______Phone #:______
Diagnosis/Allergy/Sensitivity:______Is this a Life-Threating Condition? YES or NO
Diagnosed by: (Circle One) PARENT Health Care Provider Non-Diagnosed
Call Parents When (describe specific symptoms-examples on back of form):______
Call 911When (describe specific symptoms-examples on back of form):______
What to do while waiting for parents(s) or medical help to arrive:______
______
______
Complete the Medical Authorization form whenever you administer any medication, including an Epi-Pen or Inhaler.
Medication Expiration Date:______Date of Trainig:______Training Conducted by:______
Fill out an Illness/Incident Report when non-emergency changes are observed in a child’s health/behavior but use an Incident Report-State of Michigan (BCAL4605) for emergency situations. These forms must be completed and sent home on the date of the incident/emergency.
I have helped develop this Emergency Care Plan on ______(date). I will communicate with my child’s teacher regarding any changes in treatment or diagnosis. I understand if my child’s medication expires, s/he may be unable to attend school until we have a current prescription.
Parent/Guardian Signature: ______
Procedure Was Reviewed By All Staff Including Subs:
Date Reviewed:______(Orientation) All Staff Initials: ______
Date Reviewed:______All Staff Initials:______
(4 Months from Orientation or sooner if necessary)
Reference: R400.8161 (8), HSPPS 1302.41 (a)(b)
Original: Place in Child’s file Copy: Parent, Site Supervisor, CC Provider, CCSC, and Bus Driver Attach to Child Information Record in the Classroom and on the Bus.
7/17 P:\Head Start Files\UNIVERSAL\HEALTH\Emergency Care Plan.doc
Symptoms of an Allergic Reaction:
(All symptoms can potentially progress to a LIFE-THREATENING situation)
GENERAL: Dizziness, loss of conscience, feeling of panic or doom
MOUTH: Swelling of lips, tongue, face, throat, mouth may “feel hot”
BREATHING: Wheezing, breathing difficulty, congestion, cough, throat tightness
STOMACH: Discomfort, nausea, vomiting, abdominal cramps, diarrhea
SKIN: Hives, rash, swelling
Symptoms of an Asthma Episode:
Changes in Breathing: Coughing, wheezing, mouth breathing, shortness of breath
Verbal Reports of: Chest tightness, chest pain, can’t breathe, neck feels funny, difficulty speaking
Appears: Anxious, sweating, nauseous, fatigued, stands/sits hunched over, cannot speak
Symptoms of a Seizure Episode: (may include any/all of these)
Tonic-Clonic (Grand mal) Seizure: Entire body stiffens, jerking movements, may cry out, turn bluish, be tired afterwards
Absence (Petite mal) Seizure: Staring spell, may blink eyes, loss of eye contact, twitching of arms or leg muscles
R400.8161 (8)
Each staff member shall be trained at least twice a year on duties and responsibilities for all emergency procedures.
1302.41 (a)(b)
(a) For all activities described in this part, programs must collaborate with parents as partners in the health and well-being of their children in a linguistically and culturally appropriate manner and communicate with parents about their child’s health needs and development concerns in a timely and effective manner.
(b) At a minimum, a program must:
(1) Obtain advance authorization from the parent or other person with legal authority for all health and developmental procedures administered through the program or by contract oragreement, and, maintain written documentation if they refuse to give authorization for health services; and,
(2) Share with parents the policies for health emergencies that require rapid response on the part of staff or immediate medical attention.
Reference: R400.8161 (8), HSPPS 1302.41 (a)(b)
Original: Place in Child’s file Copy: Parent, Site Supervisor, CC Provider, CCSC, and Bus Driver Attach to Child Information Record in the Classroom and on the Bus.
7/17 P:\Head Start Files\UNIVERSAL\HEALTH\Emergency Care Plan.doc