Forms

Allergies

• Utah Allergy/Anaphylaxis Healthcare Plan
• Epinephrine Authorization Form

Asthma

• Asthma Action Plan, Medication Authorization and Self-Administration (State Form)
• Asthma Action Plan, Medication Authorization and Self-Administration (Spanish)
• Asthma Medication Authorization & Inhaler Authorization Self-Administration Form
• Is the Asthma Action Plan Working? (Tool Kit, NIH)
• Steps to follow for an Asthma Episode in School
• Help Paying for Asthma Medicine

Diabetes

• Insulin Administration in School Setting (PCH)
• Diabetes Medication/Management Orders (DMMO, State Form)
• Diabetes Emergency Action Plan (State Form)
• Utah Diabetes Individualized Healthcare Plan
• CGM Addendum to IHP

American Diabetes Association (ADA)

• 504 Plan Template (ADA)
• Blood Glucose Tracking Sheet 

Primary Children’s Hospital Guidelines

• Insulin to Carbohydrate Ratios
• Correction Doses
• PCH insulin dosing cards

Medication

• Authorization for Student Medication
• Medication Log
• Medication Guidelines
• Sample Error Form

Seizures

• Seizure Action Plan
• Seizure Medication Management Order (SMMO)
• Guidelines for Seizures in Schools
• Volunteer Skills Checklist
• Volunteer Documentation Form
• STARR Poster
• Seizure First Aid Poster
• Volunteer Intranasal Presentation
• Intranasal Video
• Intranasal Post-Test
• Volunteer Rectal Medication
• Rectal Video
• Rectal Post-Test
• Sample Seizure Log
• Volunteer Training Certificate
• Training Stipend Form

Vision Screening Guidelines

• Annual Vision Report
• Sample Opt-Out Form
• School Vision Screening Guidlines
• Symptoms Questionnaire
• Vision Certificate
• Vision Referral and Report Form
• Vision Training Module A: Vision Screening Basics
• Module B: Training for Volunteers
• Module C: Tier 2 Vision Screening

Generic Individualized Healthcare Plan/Emergency Healthcare Plan

• Generic IHP