Colorado schools and child care programs use this one-page statewide plan both as the student's asthma care plan and as the health care provider's order for the quick-relief inhaler. Green, yellow and red zones set pretreatment before strenuous activity, dosing for mild symptoms and emergency steps with a call to 911. The plan is good for 12 months unless district policy says otherwise.
The parent or guardian completes and signs the top section. The student's physician, NP or PA completes all provider items (quick-relief medication, triggers, self-carry choice, pretreatment and zone puffs) and signs; the school nurse or child care health consultant signs last.
Download the current version from the source each time; forms change without notice.
Colorado Asthma Care Plan and Medication Order for School and Child Care Settings
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The form says it is good for 12 months unless specified otherwise in district policy. It serves as both the care plan and the provider's medication order, and the parent's signature approves the plan and commits the family to supply prescribed, non-expired medication and supplies such as a spacer.
Yes, when the provider checks that the student understands proper use of asthma medications and can self-carry and use the inhaler independently. The form makes that subject to approval from the school nurse and completion of a self-carry contract, which CDE posts along with a student self-carry readiness tool.