Doing What’s Best for Kids

Students AP 316 - Form 316-3: School Medical Response Plan Template

Student Name & Grade

Medical Diagnosis:
Medical Doctor:
Date of Diagnosis:

Reaction Symptoms/Signs:
Medication to be Administered:
Method of Administration:
Note: Medication Expiry Date:
Location of Medication or Device:
Staff trained in First Aid/Administration of Medication:
 This plan is linked to the School’s Emergency Response Plan (Staff Initial:        )

Emergency Procedures to Follow:
1. Stay with the student
2. Administer medication
3. Contact office to contact parents
4. _
5. _
6. _
If THE STUDENT HAS any of the following:
- unresponsive / unconscious
- unable to swallow (DO NOT GIVE ANYTHING BY MOUTH)
1. CALL "911" IMMEDIATELY Place student in the “recovery position”
2. Call parents IMMEDIATELY

This Medical Response was reviewed by the parent _________________and _________________________(staff member) on ____________________(date). Information contained in this plan will be shared with other students and staff on a need to know basis to ensure student safety.

Parent Signature 

Staff Member Signature 

Medical Professional (recommended)