Certain Entity/Venue Information
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Remember to report this information to the school administrator, the prescribing physician and the student’s primary healthcare provider and keep a copy in the student’s permanent record.
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Spell out the school district, open-enrollment charter school, or private school’s name.
Do not use an abbreviation.
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Location and Dosage Information
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(Examples: nurse’s office, classroom, hallway, etc. A mailing address is not needed.) |
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(Example: 2 puffs = 1 dose)
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(Must be a school nurse, as defined by statute: School nurse--Registered nurse, as defined in 19 TAC §153.1022, authorized to administer asthma medication, or licensed vocational nurse working under supervision as described in Texas Occupations Code §301.353.)
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Other Information
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Symptom Information
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Please select the symptoms the individual who got the unassigned asthma medication was exhibiting. Mark all that apply.
If no respiratory symptoms occurred, choose “N/A” and write symptoms in the “other” category. *
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Suspected Asthma Triggers
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Please indicate the suspected cause or trigger of the asthma attack
(Check all that apply*):
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Remember to replace the unassigned asthma medication and the equipment used to administer the medication.
If you used a metered dose inhaler, make sure you wipe it down with a sterilizing solution.
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