Seizure Care Plan Page 2
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1
2
3Other Professionals Involved
Telephone
Health Care Provider
:
(MD, NP, etc.)
Occupational Therapist:
Physical Therapist:
Neurology Specialist:
Other:
Specific Medical Information
v Medical documentation provided & attached:
o Yes
o No
Information Exchange Form
completed by Health Care Provider on-file.
o
Any known allergies to food and/or medications: ____________________________________________________________
v Medication to be administered:
o Yes
o No
Medication Administration Form
completed by Health Care Provider and parents is on file
o
(including: type of medications,
method, amount, time schedule, potential side effects, etc.)
Special Staff Training Needs
Type
: ____________________________________________________________________________________
(be specific)
Training done by: _________________________________
Date of Training:_________________________
Additional Information (
include any unusual episodes/behavior changes that might arise while in care and how the situation should be handled)
Support Program the Child is Involved With Outside of Child Care
Name of program:
Address and telephone:
Contact person:
Emergency Procedures
__________________________
o Special emergency and/or medical procedure required. Emergency instructions:
v Call 911 if:
o Seizure lasts longer then ____ minutes.
o Child is unresponsive after seizure.
o Other:
Emergency contact:
Telephone:
Follow-up: Updates/Revisions
This Seizure Care Plan will be updated/revised whenever medications or child’s health status changes, or at least every 12 months as
a result of the collective input from team members.
Date for revision and team meeting: ________________________
California Childcare Health Program (CCHP)
07/03
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