Higley Unified School District #60

Higley Unified School District #60 Primary Care Provider Authorization: Gastrostomy/J-Tube Feeding (side one)

School Year: ______

Student Name: ______Date of Birth: ______School: ______Grade: ______

Type of Gastrostomy Tube: Feeding Times: ______Button Catheter Other (Specify) ______Name of Formula: ______*Feeding formula must be sent to school in the original unopened container or physician orders for parent/guardian to make/mix Pump to be used: Yes May additional water be administered during No warm weather? Yes Flow Rate: ______cc/hour No Amount _____cc

Type of Pump: Gravity: Yes No Volume to be given: ______cc over ______minutes Additional health care provider’s comments : Volume of water to follow each feeding: ______cc ______

Positions: During Feedings: ______No feedings or care needed at this time during school: After Feedings: ______*Student will need new physicians orders if this changes*

Please complete both sides of this form: Form must be signed by Health Care Provider and Parent/Guardian

Higley Unified School District #60 Primary Care Provider Authorization: Gastrostomy Tube Feeding (side two)

School Year: ______

Student Name: ______Date of Birth: ______School: ______Grade: ______

EMERGENCY PLAN OF ACTION 1. School personnel cannot forcefully flush OR replace a tube into the stomach. If the gastrostomy tube becomes dislodged then school staff will place gauze and tape over the site and parent/guardian will be informed. If indicated in physician orders EMS will be called to have student transported to medical facility. 2. The parent/guardian will be notified immediately if a tube becomes clogged or dislodged. 3. If unable to reach parent/guardian within 30 minutes of tube becoming dislodged AND/OR they are unable to get to the school within 1 hour of tube becoming dislodged, call EMS 911, unless written physician orders state otherwise. 4. When student is transported via EMS a HUSD staff member must ride with the student unless parent/guardian or emergency contact accompanies them. 5. If student requires medical treatment while on the bus, the driver will contact EMS. 6. Other: ______

Form must be signed by Health Care Provider and Parent/Guardian.

______Printed Name/Physician Address Date

______Signature/ Physician Telephone Number Fax Number

Parent and/or Legal Guardian: As the parent/legal guardian I hereby request and authorize the school nurse, health aide, or other school personnel to administer the medical procedures authorized by the physician named above to the Student. I agree to furnish all equipment, medications, supplies, formulas, or other items necessary for the administration of the services and/or procedures and to provide replacements and maintenance as necessary. I agree to notify the School Health Office immediately if there are any changes in the Student’s medical condition or physician’s orders that impact the School’s responsibilities to the Student or that may impact the Student during the school day. Signing this form shall release the Higley Unified School District and its employees from liability of any nature that might result from this plan of action. I also acknowledge that gastrostomy care/feedings and the emergency plan of action will most likely be administered by trained, unlicensed Higley Unified School District personnel.

______Signature of Parent/Guardian Telephone Number Date