Accessibility Resource Center
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Release of Information and Procedures for Emergency Medical Occurrence Form

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.