Cobb County School District
Cobb County School District Form JGCD-11 Empowering Dreams for the FutureDOCTOR’S ORDERS FOR EMERGENCY SEIZURE MEDICATION(including, but not limited to Diazepam, Diastat, Midazolam, and Versed)Student’s Name: FORMTEXT ?????Weight: FORMTEXT ?????kg FORMTEXT ?????lbsBirth Date: FORMTEXT ?????Grade: FORMTEXT ?????School: FORMTEXT ?????Diagnosis: FORMTEXT ?????Medication:Diastat/Diazapam Rectal GelDose: FORMTEXT ?????Route: RectallyVersed/Midazolam Intranasal SprayDose: FORMTEXT ?????Route: IntranasalOther: FORMTEXT ?????Dose: FORMTEXT ?????Route: FORMTEXT ?????CHECK YOUR SPECIFIC TREATMENT ORDERS BELOW:INDICATION FOR THE ADMINISTRATION OF Emergency Seizure Medication (including, but not limited to Diazepam, Diastat, Midazolam, and Versed): FORMCHECKBOX Generalized seizure of 5 minutes or greater duration FORMCHECKBOX Two or more consecutive seizures (without a period of consciousness between) that last 5 minutes or more FORMCHECKBOX Other: FORMTEXT ?????CONTRAINDICATION(S) (Please Print): FORMTEXT ????? FREQUENCY OF ADMINISTRATION OF Emergency Seizure Medication (including, but not limited to Diazepam, Diastat, Midazolam, and Versed): In accordance with manufacturer’s FDA approved recommendation, the Cobb County School District will not administer Diastat Rectal Gel more than once in a five (5) day period unless the student’s physician orders otherwise below. For this student, when indicated as marked above, Emergency Seizure Medication (including, but not limited to Diazepam, Diastat, Midazolam, and Versed): FORMCHECKBOX May only be administered once every five (5) days per the manufacturer’s recommendation. FORMCHECKBOX A second dose may be administered 4 to 12 hours after the first dose. FORMCHECKBOX May be administered FORMTEXT ????? times every FORMTEXT ????? (specify a number of hours OR days). Name of Physician (Please Print): FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Physician Signature:andGeorgia Board Certification Number: FORMTEXT ?????Date*: FORMTEXT ?????*This order will be valid for one calendar year from the date of the physician’s signature. ................
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