| 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.
*Make sure that you have a signed release of information form from the parent
before sharing information with a Physician!
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.
*Make sure that you have a signed release of information form from the parent
before sharing information with a Physician!
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.
 | |  | |  | |  | |  | |  |
s.a.m.p.
s.a.m.p.