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Legal Rights of Children with Epilepsy in School & Child Care

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(STUDENT’S NAME): REPORT FROM HOME<br />

Date:<br />

After school/even<strong>in</strong>g activities yesterday:<br />

Seizures: Yes___ No___<br />

If yes, # <strong>of</strong> seizure episodes_________<br />

Length <strong>of</strong> seizure episode(s)___________<br />

Time seizure(s) occurred__________________________<br />

Type(s) <strong>of</strong> seizure(s)__________________________________________<br />

Sleep afterwards? Yes___ No____<br />

Emergency medication used? Yes/Type ______________________________ No_____<br />

Other care provided____________________________________<br />

Additional <strong>in</strong>formation_________________________________<br />

Appetite this morn<strong>in</strong>g:<br />

Other news:<br />

Contact Information for Today: ____________________ ___________________<br />

Name<br />

Telephone Number<br />

Back-up Contact Person for Today: ___________________<br />

Name<br />

__________________<br />

Telephone Number<br />

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