Seizure Action Plan (School)

Student Name: [Full legal name; include preferred name if different] Date of Birth: [MM/DD/YYYY] Grade/Classroom: [Grade and classroom]

School: [School name] School Year: [YYYY–YYYY]

Plan Effective Date: [MM/DD/YYYY] Last Updated: [MM/DD/YYYY] Review Due: [MM/DD/YYYY]

(If information is missing for any field, retain the field with "Information needed" rather than omitting.)

Contacts

Parent/Guardian: [Name(s), phone(s)]

Emergency Contact: [Name, relationship, phone]

Neurology Provider: [Name, phone]

Primary Care Provider: [Name, phone]

Preferred Hospital: [Hospital name, if specified]

Emergency Response

Seizure First Aid (All Seizures):

• ☐ STAY with student; note time seizure started
• ☐ SAFE: move hazards away, protect head, do not restrain
• ☐ SIDE: turn on side if not awake/alert; keep airway clear; nothing in mouth
• ☐ SUPPORT: stay until fully recovered; provide calm reassurance

Call 911 If:

• ☐ [Student-specific EMS criteria from prescriber, if provided]
• ☐ Seizure lasts longer than [5 minutes / individualized threshold]
• ☐ Breathing difficulty or color change
• ☐ Seizure occurs in water
• ☐ Injury during seizure
• ☐ Repeated seizures without full recovery between
• ☐ First known seizure

Rescue Medication:

(Include one of the following based on whether rescue medication is ordered.)

If no rescue medication authorized: No rescue medication authorized at school.

If rescue medication ordered:

• Give [Medication name] [Exact dose] via [Route] IF seizure lasts ≥ [X] minutes [or cluster definition if applicable]
• Administration: [Step-by-step instructions]
• May be given by: [School nurse / Trained designated staff / Student self-administration]
• Repeat dose: [Timing and maximum if allowed / Do not repeat without medical direction]
• After giving: Call 911 if seizure continues [X] minutes after dose; notify parent/guardian; document time, dose, and response

(If medication name, exact dose, route, or indication criteria are incomplete, display the following warning.)

⚠ Rescue medication order incomplete—do not administer until complete written order is obtained from prescriber.

VNS Magnet: [Location of magnet; swipe instructions; when to repeat / N/A if no VNS]

Seizure Profile

(Repeat for each seizure type the student experiences.)

[Seizure type name]:

• Looks like: [Observable behaviors in plain language]
• Typical duration: [Duration range]
• Recovery: [Time to baseline; postictal behaviors]
• Special instructions: [Type-specific first aid or escalation notes, if any]

(If seizure type is not fully characterized, describe observable features and apply conservative escalation criteria.)

Baseline Status: [Student's typical communication, mobility, and behavior when not having a seizure]

Known Triggers: [Identified triggers such as sleep deprivation, missed medication, illness, stress, photosensitivity / None identified]

Allergies/Relevant Medical History: [Only information affecting emergency response]

Recovery & Return to Activity

Post-Seizure Care: [Observation location; supervision requirements; reorientation and reassurance approach]

May Return to Class When: [Criteria such as: returned to baseline alertness, stable gait, tolerating activity per nurse assessment]

Send Home If: [Criteria such as: prolonged postictal state beyond typical, recurrent seizures, injury, rescue medication given, EMS activated] (If individualized criteria not specified, defer to school nurse judgment.)

Authorization

Parent/Guardian Signature: ______________________ Date: ______

Prescribing Clinician Signature: ______________________ Date: ______
[Printed name, credentials, phone]

School Nurse Review Signature: ______________________ Date: ______

Acknowledgments:

• ☐ I understand when 911 will be called.
• ☐ I understand who may administer rescue medication per school policy (if applicable).
• ☐ I authorize sharing this plan with school staff responsible for my child's supervision.