condition specific action plan
Condition-specific action plan: Cover page [Condition] _________________________________________________ action plan for: ________________________________________________________ [child’s name]
Date developed: ________________________________________________ Review date(s): _________________________________________________ Note: Review this information with the parents every 6 months or whenever their child’s treatment changes.
CHILD’S PHOTO
Child’s birth date: _______________________________________________ Child’s weight: __________________________________________________
Designated staff member (if applicable): _____________________________________________________________
Contact information Mother/guardian: ______________________________________________________________________________ Tel: Home _________________________ Work _______________________ Cell __________________________ Father/guardian: ______________________________________________________________________________ Tel: Home _________________________ Work _______________________ Cell __________________________ Child lives with: _______________________________________________________________________________ Child’s doctor’s name: ____________________________________________ Tel: __________________________ Allergy specialist’s name (if applicable): __ Tel: ________________________ Alternate emergency contact (if parents are unavailable): ______________________________________________ Relationship to child: ___________________________________________________________________________ Tel: Home _________________________ Work _______________________ Cell __________________________ Notify parents/guardians or emergency contact in the following situations: _________________________________ ____________________________________________________________________________________________ Note any other conditions that may affect the treatment of this child: _____________________________________ ____________________________________________________________________________________________ Name, address and phone number for child care centre or home setting
© Canadian Paediatric Society, 2008. Reprinted from Well Beings: A Guide to Health in Child Care (3rd edition). May be reproduced for educational purposes, and for use in child care settings.
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Date developed: ________________________________________________ Review date(s): _________________________________________________ Note: Review this information with the parents every 6 months or whenever their child’s treatment changes.
CHILD’S PHOTO
Child’s birth date: _______________________________________________ Child’s weight: __________________________________________________
Designated staff member (if applicable): _____________________________________________________________
Contact information Mother/guardian: ______________________________________________________________________________ Tel: Home _________________________ Work _______________________ Cell __________________________ Father/guardian: ______________________________________________________________________________ Tel: Home _________________________ Work _______________________ Cell __________________________ Child lives with: _______________________________________________________________________________ Child’s doctor’s name: ____________________________________________ Tel: __________________________ Allergy specialist’s name (if applicable): __ Tel: ________________________ Alternate emergency contact (if parents are unavailable): ______________________________________________ Relationship to child: ___________________________________________________________________________ Tel: Home _________________________ Work _______________________ Cell __________________________ Notify parents/guardians or emergency contact in the following situations: _________________________________ ____________________________________________________________________________________________ Note any other conditions that may affect the treatment of this child: _____________________________________ ____________________________________________________________________________________________ Name, address and phone number for child care centre or home setting
© Canadian Paediatric Society, 2008. Reprinted from Well Beings: A Guide to Health in Child Care (3rd edition). May be reproduced for educational purposes, and for use in child care settings.
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