RELEASE
OF INFORMATION AND PROCEDURES FOR
EMERGENCY
MEDICAL OCCURRENCE
STUDENT:___________ 1D#___________ DATE:___________ TERM:
The following
information is provided with my express permission to provide an informed
environment for me at University
of North Carolina-Pembroke. I am aware of
the contents and agree to it being released confidentially to Public Safety,
Student
Health Services,
and instructors in whose classes I am registered this semester.
Student
Signature___________ Date
_________________________________
INSTRUCTIONS
SPECIFIC TO MY MEDICAL CONDITION:
1.
Nature of condition____
2.
Frequency
Duration_________ Intensity
___________________________________
3.
The best method of assistance.
____________________________________________________________________
4.
Length of time to
wait before calling an ambulance.
___________________________________________________
5.
Preferred
Hospital
_____________________________________________________________________________
6.
Family/Friend to
call
_____________________________________________________________________________
7.
Other information
______________________________________________________________________________
INSTRUCTIONS
SPECIFIC TO SEIZURE DISORDER:
1. Type of
seizure disorder. ________________________________
2.
Frequency Duration Intensity
________________________________________
3.
The best method
of assistance____
4.
Length of time to
wait before calling an ambulance,
5.
Preferred
hospital_____
6.
Family/friend to
call_____
7.
Other
information
GENERAL
INSTRUCTIONS FOR ANY SEIZURE OCCURRENCE
1. Faculty instructs
class member to call Public Safety, # 6235 and Student Health Services,
#6219.
2.
Faculty instructs
students to clear an area and waft in the hall to give the student
privacy.
3.
Faculty (or
Public Safety) assists the student in lying down (assuming this is the plan of
action in procedural process
described
above).
4.
The attending person makes sure
there are no obstructions in the student's mouth and places a soft object under
his/her
head.
5.
If the seizure
continues longer than the time stated above, Public Safety may, at their
discretion, call the ambulance.
6.
If the seizure
ends in the specified time and the student feels recovered, he/she may rejoin
the class.
7. If the student is
fatigued, the designated person may be contacted to pick up the student or the
student may go to Student
Health
Services.