SCHOOL ASTHMA ACTION PLAN This record is to be completed by parents/carers in consultation with their child’s doctor. Please tick the appropriate box and print your answers clearly in the blank spaces where indicated. This school is collecting information on your child’s asthma so we can better manage asthma while your child is in our care. The information on this Plan is confidential. All staff that care for your child will have access to this information. It will only be distributed to them to provide safe asthma management for your child at school. The school will only disclose this information to others with your consent if it is to be used elsewhere. Please contact the school at any time if you need to update this Plan or you have any questions about the management of asthma at school. If no Asthma Action Plan is provided by the parent/carer, the staff will treat asthma symptoms as outlined in the Victorian Schools Asthma Policy (Section 126.96.36.199 of the Department of Education and Early Childhood Development Victorian Government Schools’ Reference Guide). Student’s Name
Gender M F Age __________ Date of birth _____/_____/_____ Form/Class ___________ Emergency Contact (e.g. Parent/Carer) __________________________ Relationship __________ Phone: (H) ______________________ (W) ______________________ (M) _____________________ Doctor’s Name __________________________________________ Phone ___________________ Ambulance Subscriber Yes No Subscriber number __________________________ Does this student have any other health plans? Yes No If so what are they?______________________________ USUAL ASTHMA ACTION PLAN Usual signs of student’s asthma Worsening signs of student’s asthma What triggers the student’s asthma? Managing Exercise Induced Asthma (EIA)
Students with asthma are encouraged to take part in school based exercise and physical activity to contribute to their cardiovascular fitness and general wellbeing. Most individuals with EIA can exercise to their full potential if the following steps are taken:
1. Students should take their blue reliever medication 5-10 minutes before warm up, then warm up appropriately.
2. If the student presents with asthma during the activity the student should stop the activity, take their blue reliever
medication and wait 4 minutes. If the symptoms improve, they may resume activity. If their symptoms reoccur, recommence treatment. THE STUDENT SHOULD NOT RETURN TO THE ACTIVITY UNDER ANY CIRCUMSTANCES and the parent/carer should be informed of any incident.
3. Cool down at the end of activity and be alert for asthma symptoms after exercise.
Does the student need assistance taking their medication? Yes No If yes, how? ______________________ Asthma medication requirements usually taken: (Including relievers, preventers, symptom controllers, combination)
(e.g. puffer & spacer, dry powder inhaler) (e.g. at home, 1 puff in morning and
The Asthma Foundation of Victoria June 2008
SCHOOL ASTHMA ACTION PLAN Asthma First Aid Plan Please tick preferred Asthma First Aid Plan Victorian Schools Asthma Policy for Asthma First Aid
(Section 188.8.131.52 of the Department of Education and Early Childhood Development Victorian Government Schools’ Reference Guide)
1. Sit the student down and remain calm to reassure them. Do not leave the student alone.
2. Without delay shake a blue reliever puffer (Airomir, Asmol, Epaq or Ventolin)* and give 4 separate puffs through a
spacer (use the puffer alone if a spacer is not available). Use one puff at a time and ask the student to take 4 breaths from the spacer after each puff.
3. Wait 4 minutes. If there is no improvement, repeat steps 2 and 3.
4. If there is still no improvement after a further 4 minutes – call an ambulance immediately (dial 000) and state that
the student is having breathing difficulties. Continuously repeat steps 2 and 3 while waiting for the ambulance.
* A Bricanyl Turbuhaler may be used in First Aid treatment if a puffer and spacer is unavailable
If at any time the student’s condition suddenly worsens, or you are concerned, call an ambulance immediately.
Student’s Asthma First Aid Plan (if different from above)
• Please notify me if my child regularly has asthma symptoms at school.
• Please notify me if my child has received Asthma First Aid.
• In the event of an asthma attack, I agree to my son/daughter receiving the treatment described above.
• I authorise school staff to assist my child with taking asthma medication should they require help.
• I will notify you in writing if there are any changes to these instructions.
• I agree to pay all expenses incurred for any medical treatment deemed necessary.
Parent’s/Guardian’s Signature: _______________________________________
Doctor’s Signature: ________________________________________________
For further information about the Victorian Schools Asthma Policy, the Asthma Friendly® Schools Program or asthma management please contact The Asthma Foundation of Victoria on (03) 9326 7088, toll free 1800 645 130, or
The Asthma Foundation of Victoria June 2008
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