Important Forms

Forms for School Nurses and Parents

The sample forms linked below provide guidelines for collecting data relevant to educational planning for students with epilepsy and can be adapted to meet individual and institutional needs. Each form requests information critical to appropriate health management planning, which can occur only if the data are used collectively.

• Questionnaire for Parents -English
• Questionnaire for Parents - Spanish

To be completed by the student's parent(s). In some cases the school nurse may need to interview the parent(s) to clarify and fill in the information requested. The form should be updated annually or when any changes occur and will assist school personnel in recognizing a student's seizure(s), responding appropriately, and planning.

 

• Student Interview Form
  

To be completed by the school nurse through an interview with the student. The student's understanding of his or her epilepsy will provide valuable information in health management planning. The form should be updated every six months or when changes occur.

 

• Seizure Action Plan - English
• Seizure Action Plan - Spanish
  

Designed to provide basic information about a student's seizure(s), and medication, as well as what school personnel should do for the student during a seizure. It should be distributed at the beginning of a school year, when a diagnosis is made or when a change in health status occurs.

 

• Teacher's Observation Record
  

To be completed by school personnel when reporting a seizure(s) and/or medication side effects.