1. Seizure description
      2. Actions to take during seizure
      3. Frequency of seizure
      4. Typical seizure duration
      5. School Administrator Signature:
      6. Date Signed:
      alt
      NIAGARA CATHOLIC DISTRICT SCHOOL BOARD

      INDIVIDUAL STUDENT EPILEPSY PLAN OF CARE
      November 2022
       
      1. STUDENT PROFILE and INFORMATION
      Date Completed:
      		YYYY-MM-DD
      Student Name
      Birth Date
      		YYYY-MM-DD Age 00
      Current School
      Current Grade
      		00 OEN 000-000-000
      Teacher(s)
      Parent/Guardian
      Phone
      Other Medical Conditions or Allergies  

       
      2. EMERGENCY CONTACTS Listed in priority:
       
      Name
      Relationship to Student
      Preferred Phone
      Alternate Phone
      1
      		    
      2
      		    
      3
      		    

       
      3. EMERGENCY RESCUE MEDICATION
      Has the student been prescribed an emergency rescue medication? YES ☐ NO ☐
      If YES, attach the rescue medication plan, healthcare providers’ orders and authorization from the students’ parents/guardians for a trained person to administer the medication.
      NOTE: Rescue medication training for the prescribed rescue medication and route of administration (e.g., buccal, or intranasal) must be done in collaboration with a regulated healthcare professional.  

      4. KNOWN SEIZURE TRIGGERS Check all that apply:
      ☐ Stress ☐ Changes in diet ☐ Illness
      ☐ Change in weather ☐ Mensural cycle ☐ Lack of sleep
      ☐ Improper medication balance ☐ Inactivity ☐ Electronic stimulation (video, lights)
      ☐ Other: ☐ Other: ☐ Other:  
      5. DAILY ROUTINE EPILEPSY MANAGEMENT  
      Description of Non-convulsive Seizure
      Action 

      (       e.g., trigger avoidance, dietary therapy, risks to mitigate)
        
      Description of Convulsive Seizure
      Action
        

       
      6. SEIZURE MANAGEMENT  

       
      Seizure Type (e.g., tonic-clonic, absence, etc.)



      Seizure description



      Actions to take during seizure



      Frequency of seizure



      		Typical seizure duration  



      As a person may have more than one seizure type, record information for additional type(s) below. Duplicate this section as needed.

      Seizure Type (e.g., tonic-clonic, absence, etc.)
      Seizure description
      Actions to take during seizure
      Frequency of seizure Typical seizure duration
      7. BASIC FIRST AID: CARE and COMFORT  
      First Aid Procedures
      Does the student need to leave the classroom after a seizure episode? YES ☐ NO ☐
      If YES, describe the process for returning the student to the classroom below:
      BASIC SEIZURE FIRST AID
      		FOR TONIC-CLONIC SEIZURE EPISODES:
      ·   Stay calm and track time/duration of seizure

      ·   Keep student safe

      ·   Do not restrain or interfere with student’s movements

      ·   Do not put anything in student’s mouth

      ·   Stay with student until fully conscious
      		·   Protect student’s head

      ·   Keep airway open/watch breathing

      ·   Turn student on side  
      8. EMERGENCY PROCEDURES  
       


      Students with epilepsy will typically experience seizures as a result of their medical condition.

       

      Call 911 when:

       

      ·   Convulsive (tonic-clonic) seizure lasts longer than five minutes.

      ·   Student has repeated seizures without regaining consciousness.

      ·   Student is injured or has diabetes.

      ·   Student has breathing difficulties.

      ·   Student has a seizure in water.

       

      Notify parents/guardians or the emergency contacts in Section 2.

       
      9. PARENT PRE-AUTHORIZATION and CONSENT FOR EPILEPSY INTERVENTIONS
      Student Name  
      Birth Date
      		YYYY-MM-DD Age 00
      Current School  
      Current Grade
      		00 OEN 000-000-000
      Parent/Guardian  
      Phone
      Address  

       
      Consent to release and share information*: I/we authorize and provide consent to school staff to use and/or share information in this plan for purposes related to the education, health, and safety of my/our child. This may include:


      1.  Displaying my/our child’s photograph and/or additional information on paper notices or electronic formats(s) so that staff, volunteers, and school visitors will be aware of my/our child’s medical condition

      2.  Communicating with bus operators

      3.  Sharing information in special circumstances to protect the health and safety of my/our child.
      Consent to transfer to hospital: I/we consent in advance to my/our child’s being transported to a hospital if required, based on the judgement of school staff. I/we also permit a staff member to accompany my child during transport. I/we agree that the school’s administrator or designate shall decide if an ambulance is to be called, and to assume responsibility for all costs associated with any medical intervention.
      Consent to treatment: I/we am aware that school staff are not medical professionals and perform all aspects of this plan to the best of their abilities and in good faith. I/we approve of the management steps and responses outlined in this care plan.
      Consent for annual review: I am/we are aware that school staff will request my/our involvement in an annual review of this management plan, and when requirements change significantly, they will request my/our involvement in completing a new plan.
      Parent/Guardian (Print):
      		 
      Parent/Guardian Signature(s):
      		 
      Date Signed:
      		 

       



      School Administrator Signature:



       
      Date Signed:
      		 

       

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      *This information is being collected pursuant to the provisions of the Municipal Freedom of Information and Protection of Privacy Act and under the Authority of the Education Act and will be used by Student Support. Questions about this collection should be directed to the Superintendent of Education – Student Support, Niagara Catholic District School Board, 427 Rice Road, Welland, Ontario L3C 7C1, 905-735-0240.