Prevalent Medical Conditions - Required Medical Plans of Care
This message is intended for the families of students with prevalent medical conditions where documentation is needed by the school.
To ensure we are able to support the needs of your student, we ask that you take the time to complete the appropriate medical forms that are applicable to each of your children. We are asking you to complete these in a digital format. Please e-mail all the forms to the school when completed – polso@limestone.on.ca
All medical forms are accessible through the Limestone District School Board website. Click HERE (choose Section 300 - Student Related Forms) or click on links below to access all the information and documentation we require you to submit to the school.
These Plans of Care are for children with diagnosed medical conditions that may require intervention and/or support at school.
Please note the following:
For Epilepsy, the following forms are required:
Plan of Care - Epilepsy - Form 311-B
If the diagnosis of Epilepsy also requires emergency seizure rescue medication to be administered, then Physician’s Authorization and Request for the Administration of Prescribed Medication - Form 314-A1 (This form MUST BE completed and signed by the physician. You could request to have the physician e-mail it directly to the school at polso@limestone.on.ca) and Authorization and Request for Administration of Epi-Pen, Glucagon, Emergency Seizure Medication - Form 314-A3 are required. If a designated medical procedure (Emergency Seizure Medication) is required and will be administered at school, it is also necessary to complete Authorization and Request for the Administration of Medical Procedures - Form 314- B1.
For Diabetes, the following forms are required:
Plan of Care - Diabetes - Form 311-C
If the diagnosis of Diabetes also requires emergency rescue medication to be administered, Physician’s Authorization and Request for the Administration of Prescribed Medication - Form 314-A1 (This form MUST BE completed and signed by the physician. You could request to have the physician e-mail it directly to the school at polso@limestone.on.ca) and Authorization and Request for Administration of Epi-Pen, Glucagon, Emergency Seizure Medication - Form 314-A3 are required. If a designated medical procedure (Glucagon, glucose monitoring) is required and will be administered at school, it is also necessary to complete Authorization and Request for the Administration of Medical Procedures - Form 314- B1.
For Asthma, the following forms are required:
Plan of Care - Asthma - Form 311-D
Also required is the Request and Authorization for the Administration of Reliever/Rescue Inhaler - Form 314-A4 (This form MUST BE completed and signed by the physician. You could request to have the physician e-mail it directly to the school at polso@limestone.on.ca).
For Anaphylaxis, the following forms are required:
Plan of Care - Anaphylaxis - Form 311-E
Also required are the Physician’s Authorization and Request for the Administration of Prescribed Medication - Form 314-A1 (This form MUST BE completed and signed by the physician. You could request to have the physician e-mail it directly to the school at polso@limestone.on.ca) and Authorization and Request for Administration of Epi-Pen, Glucagon, Emergency Seizure Medication - Form 314-A3.
For any other diagnosed medical condition (including critical allergies), please complete a General Plan of Care – Form 311-A.
If your student requires daily medication to be administered during school hours, the following forms are required:
Physician’s Authorization and Request for the Administration of Prescribed Medication - Form 314-A1. (This form MUST BE completed and signed by the physician. You could request to have the physician e-mail it directly to the school at polso@limestone.on.ca)
Authorization and Request Form for the Administration of Prescribed Medication - Form 314-A2.
If you are unsure about whether your student requires a Plan of Care, please reach out to the school by e-mail at polso@limestone.on.ca or call 613-542-5926.
These forms are extremely important for us to receive back from you so that we can support the needs of your student. No medication or procedures can be administered at school without the authorization forms signed and filed at the school.
Students at risk for anaphylactic reaction and who have prescribed Epi-pens, should carry an Epi-pen on their person if appropriate. Otherwise, this should be in a known and accessible spot in the classroom. Please ensure that your student has their Epi-pen with them and readily available when they are at school. We store the second Epi-pen at the main office.
Students with asthma who have an inhaler should carry an inhaler on their person if appropriate. Otherwise, this should be in a known and accessible spot in the classroom. Please ensure that your student has their inhaler with them and that it is readily available when they are at school.
If you have any questions or concerns, please feel free to contact the school. Thank you in advance for your attention to this important matter. We appreciate you gathering all this vital information and emailing it back to us in a timely manner so that we can fully support the needs of your child during the upcoming school year.