ࡱ> fhe? 6bjbjԠԠ 4dhhJ   888LLL8\L-^I-K-K-K-K-K-K-$(02o-8o--l8I-I-r=*T ,=+0tE#*5--0-*n3n3=+n38=+o-o-Q-n3 X f:  This form is to be completed by the students medical/health practitioner providing a description of the health condition and first aid requirements for a student with a health condition. This form will assist the school in developing a Student Health Support Plan which outlines how the school will support the students health care needs. Name of School: Name of Student: Date of Birth:  MedicAlert Number (if relevant): Review date for this form: Authorisation Page 1: Name of Medical/health practitioner: Professional Role: Signature: Date: Contact details: The Royal Childrens Hospital Direct Line; 03 9345 7072 Email; Name of Parent/Carer or adult/independent: Signature: Date:  Observable sign/reactionFirst aid responsePermcath pulled/slides outLay *** down on his back and reassure him. Apply pressure over the hole with a clean dressing or cloth. Pressure need not be excessive but must be occlusive. Call ambulance to take *** to nearest Hospital/RCHClamps on Permcath Unclamped Caps removed from end of tube/sRe apply clamps and notify parents at pickup time, or message them. Ensure clamps are closed, call ambulance and wrap ends in clean or sterile dressing. *** needs to attend hospital for antibiotics.If the line site (where tube enters the chest) appears red, swollen or any discharge from the siteCall family- Will require a medical review(Student) presents with temperature >38C Dizziness, Persistent headachesCall family- Will require a medical review Privacy Statement The school collects personal information so as the school can plan and support the health care needs of the student. Without the provision of this information the quality of the health support provided may be affected. The information may be disclosed to relevant school staff and appropriate medical personnel, including those engaged in providing health support as well as emergency personnel, where appropriate, or where authorised or required by another law. You are able to request access to the personal information that we hold about you/your child and to request that it be corrected. Please contact the school directly or FOI Unit on 96372670. Authorisation Page 2: Name of Medical/health practitioner: Professional Role: Signature: Date: Contact details: The Royal Childrens Hospital. Direct Line; 03 9345 7072 Email; Name of Parent/Carer or adult/independent: Signature: Date: If additional advice is required, please attach it to this form **Please note: Adult student is a student who is eighteen years of age and older. Independent student is a student under the age of eighteen years and living separately and independently from parents/guardians (See Victorian Government Schools Reference Guide 4.6.14.5).     M e d i c a l A d v i c e F o r m For a student with a Health Condition Description of Condition Please note that the school is responsible for (Students name) learning program during hospitalisation. The program should be negotiated with their hospital-based teachers to maximise continuity of learning and care. (Student) has severe kidney disease. His/Her kidney function is so small that he now requires the assistance of a procedure called Haemodialysis to ensure his blood is clean and he can continue to grow and attend school. In order for him to receive this treatment, he needed to have a plastic tube inserted into a large vein in his upper right chest. This tube is called a permcath. The permcath has stitches in it to anchor it to his chest, as well as a cuff along its length that his skin will grow into, and most likely has already. A clear sticky dressing provides further anchorage and together, these measures immobilise the catheter very well, preventing it from coming out. (Student) should wear clothing that keeps the tube close to his chest, such as a singlet. He cant get the tube wet, so swimming is not allowed. He should be encouraged to participate in non-contact sport at school as tolerated. Basketball and Down-ball, Cricket and Athletics are all suitable activities. Please follow the guidelines below, should there be any problems with the Permcath. The major risk of having a Permcath is infection. First Aid If Student becomes ill or injured at school, the school will administer first aid and call an ambulance if necessary. If you anticipate the Student will require anything other than a standard first aid response, please provide details on this page, so special arrangement can be negotiated.  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