Report for the Emergency Administration of Albuterol

Edited for Jolene Bracale by Don Gilroy on 02/21/2023.
Report for the Emergency Administration of Albuterol
Name of County:*
Date of Albuterol Administration:*

MonthDayYear
Route of Administration*

InhalerNebulizer
Type of Person Emergency Medication Given to*

StudentStaffVisitor
Approximate Age of Person Receiving Medication:*
Gender of Person Receiving Medication*

MaleFemale
History of Asthma*

YesNoUnknown
Specific Allergen that Triggered Asthma Event*

IllnessDustAnimalsWeatherExerciseEnvironmental IrritantsSmokeAllergic Reaction (Food or Bee Sting)StressUnknownOther
Did Asthma Symptoms Begin Prior to School?*

YesNoUnknown
Location Where Albuterol Administered*

Health ClinicClassroomCafeteriaGymnasiumPlaygroundBusOther
Albuterol Administered By*

RNLPNHealth AideNon-licensed School PersonnelSelf-administered by PersonOther
Albuterol Was*

Student’s Own Albuterol Provided to the School by the ParentStaff or Visitor’s Own AlbuterolStock Albuterol Provided by the School
Location Albuterol Was Stored*

Health ClinicCarried by the PersonOther
Was the Person Transported via EMS to a Local Medical Facility*

YesNo
If EMS was not notified, please select the reason: (check all that apply)*

Assessed, treated, symptoms resolved, and returned to classHome with parentTaken to healthcare provider by parentTransported to Emergency Medical Services (EMS) by parentParent refused EMS transportOther
Explain Why, if EMS was not Notified:
Title of Person Completing Form*

RNLPNHealth AideNon-licensed School PersonnelOther
Created for Jolene Bracale on 03/27/2017
Should be Empty: