| School Asthma Management The SAM program is geared to schools and Daycares looking to help their students with Asthma better their Self-Management. Check out our data collection sheets in the following steps: |
Step 1: Health History Form (click to download)
-This form is to be sent out to all students to help identify those
who have asthma. It also contains two questions about the
symptoms of asthma to help identify students who have asthma
symptoms and/or have not been officially diagnosed by a
physician.
Step 2: Asthma Student Information Update Form (click to download)
- This form is used annually if your school does not require a
full Health History form at the beginning of each school year.
This form may also be used 3-6 months into the school year for
students who may show asthma symptoms.
Step 3: Asthma Management Survey (click to download)
-This form is sent out to students with asthma and used to rate
his/her severity. This is to be used when there is no Asthma
Action Plan in the students chart. This form can be filled out by a
parent, a school nurse, or by the patient (if he/she is old enough)
Step 4: Physician Information Letter (click to download)
- This form is sent from the School Nurse to the student's PCP
to help communicate the health of the student and keep
everyone involved: student, parent, school nurse, PCP.
Step 5: SAM Data Collection Tool (click to download)
- This chart is to help collect the data and keep it organized. It
captures information on a monthly basis with a goal of having
every asthmatic student accounted for in categories such as:
severity, medication orders, Asthma Action Plans. And also
charts students that come in for acute asthma symptoms, for
scheduled visits, and also if they were sent back to class, home
or to the ER.
-This form is to be sent out to all students to help identify those
who have asthma. It also contains two questions about the
symptoms of asthma to help identify students who have asthma
symptoms and/or have not been officially diagnosed by a
physician.
Step 2: Asthma Student Information Update Form (click to download)
- This form is used annually if your school does not require a
full Health History form at the beginning of each school year.
This form may also be used 3-6 months into the school year for
students who may show asthma symptoms.
Step 3: Asthma Management Survey (click to download)
-This form is sent out to students with asthma and used to rate
his/her severity. This is to be used when there is no Asthma
Action Plan in the students chart. This form can be filled out by a
parent, a school nurse, or by the patient (if he/she is old enough)
Step 4: Physician Information Letter (click to download)
- This form is sent from the School Nurse to the student's PCP
to help communicate the health of the student and keep
everyone involved: student, parent, school nurse, PCP.
Step 5: SAM Data Collection Tool (click to download)
- This chart is to help collect the data and keep it organized. It
captures information on a monthly basis with a goal of having
every asthmatic student accounted for in categories such as:
severity, medication orders, Asthma Action Plans. And also
charts students that come in for acute asthma symptoms, for
scheduled visits, and also if they were sent back to class, home
or to the ER.
