Stock Bronchodilator Medication Administration Report

14.3(8) Reporting. A school district or school that obtains a prescription for stock medication shall report each medication incident with the administration of stock medication, medication error with the administration of stock medication, or the administration of a stock medication to the Department within 48 hours, using the reporting format approved by the Department.


Sign in to Google to save your progress. Learn more
Email *
District or School Name *
County Where Stock Bronchodilator Was Administered *
Date Stock Bronchodilator Was Administered *
MM
/
DD
/
YYYY
Time Stock Bronchodilator Was Administered *
Time
:
Route of Administration *
Medication was administered to whom? *
Did the individual have a self reported or provider verified history of asthma? *
Did the individual have a history of previous hospitalization or emergency department (ED) visits regarding asthma? *
If the individual who received the medication was a student or learner, did they have an established Individualized Health Plan (IHP) and an Emergency Plan prior to administration? *
Specify Trigger(s) to the respiratory event if known (select all that apply) *
Required
Please describe how exposure occured if known. If not known, just type "UNKNOWN" *
On the day of the event, did respiratory symptoms begin before school started? *
Location where symptoms were recognized (Select One) *
Symptoms (Check All That Apply) *
Required
Location where Stock Bronchodilator is stored: *
Location where Stock Bronchodilator was administered: *
Who administered the Stock Bronchodilator? *
Estimated time elapsed between communication of symptoms and administration of Stock Bronchodilator? *
Was the individual transported to a local health facility (primary care, urgent care, emergency department)? *
Describe the outcomes for the individual who receieved the Stock Bronchodilator (Check all that apply): *
Required
Did a debriefing meeting occur within 72 hours? *
If a debriefing meeting occured, identify the opportunities made available (select all that apply); If a meeting did not occur, click nonapplicable *
Required
If a debriefing meeting did not occur, please explain why?
Based on debriefing what are recommendations for change? (select all that apply) *
Required
Please provide any additional comments, such as concerns regarding incident or errors
Form Completed by (Name) *
Title/credentials if applicable *
Phone Number *
Email Address *
Form Completed On: *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of Iowa.

Does this form look suspicious? Report

Google Forms