Required Reporting of Administered Unassigned Asthma Medication to DSHS

If you are a school district, open-enrollment charter school, or private school there are reporting rules. The rules apply to unassigned asthma medication. The rule says you must report the administration of unassigned asthma medication. This requirement is in the Texas Administrative Code, Subchapter D, Title 25, Part 1, Chapter 40, Section 40.47.

Your campus must submit a report no later than the 10th business day after the date a school nurse administers unassigned asthma medication. You must send the report to all of the following:

  • school administrator
  • prescribing physician
  • student’s primary healthcare provider
  • commissioner of the Department of State Health Services (DSHS)

You must save a copy of the report in the student’s permanent record.  

Submission of this electronic form meets the reporting requirement for DSHS. Be sure to report complete and accurate information.

Please fill out the entire form and provide detailed information.
All fields with an asterisk (*) must be completed.

Certain Entity/Venue Information
Spell out the school district, open-enrollment charter school, or private school’s name.
Do not use an abbreviation.

Location and Dosage Information
(Examples: nurse’s office, classroom, hallway, etc. A mailing address is not needed.)
(Example: 2 puffs = 1 dose)
(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.)

Other Information
Did the student who got the asthma medication have a history of asthma? *
Did you notify the parent or guardian after the asthma medication was administered? *
Did you notify the prescribing physician when the asthma medication after the medication was administered? *
Did you notify the student’s primary health care provider when you administered the asthma medication? *
After the student got the asthma medication the student: *

Symptom Information
 

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. *

Symptom Information
Please list signs or symptoms not listed above, if applicable.

Suspected Asthma Triggers

Please indicate the suspected cause or trigger of the asthma attack
(Check all that apply*):
If you selected “Other”, please explain *

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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Texas School Health Program

Texas School Health Program

Required Reporting Forms

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