A two-page plan, revised in March 2023, that tells caregivers, camp counselors, coworkers or anyone nearby how to respond to a person's seizures: seizure types, first aid, rescue therapy and when to call 911 or the provider. The treating provider completes it with the patient or parent and signs it, and the family shares copies with the people who may need to act.
The treating health care provider fills in seizure information, the response steps, rescue therapy, daily medicines and medical history, then signs and dates the Provider Signature line. The patient or parent supplies contacts and signs the 'My signature' line.
Enter the person's name, birth date, address and phone, plus one emergency contact with relationship and phone. Because this version is used outside school, the emergency contact is the person caregivers, coworkers or camp staff will call when the plan says to notify someone, so it should be someone reachable wherever the patient spends the day.
Four rows, each with Seizure Type, How Long It Lasts, How Often and What Happens. Describe each type in plain words a bystander would recognize, with its usual length and frequency. Readers use the What Happens column to recognize the patient's typical events and to spot one that is different.
Check the steps you want caregivers to take: first aid (Stay. Safe. Side.), give rescue therapy according to the plan, notify the emergency contact, call 911 for transport to a named hospital, or other. This box is the summary a babysitter or coworker reads first, so check only the steps that apply to this patient.
The first aid list covers staying calm and timing the seizure, keeping the person safe, turning on the side if not awake, staying until recovered, swiping a VNS magnet and writing down what happens. The 911 list includes loss of consciousness over 5 minutes and repeated seizures over 10 minutes without recovery. The provider-first list flags pattern changes, a slow return to usual behavior and pregnancy.
Up to three orders, each with the trigger in 'If seizure (cluster, # or length)', the Name of Med/Rx, How much to give (dose) and How to give. A caregiver outside a clinical setting will act on these lines alone, so state the trigger as a count or a length of time and the route in plain words.
Describe what help the person needs after a seizure and when the person can resume usual activity. Special instructions are addressed to First Responders and the Emergency Department, so this is where to note anything paramedics or the emergency team should know about this patient's seizures and treatment.
Four rows for Medicine Name, Total Daily Amount, Amount of Tab/Liquid, and How Taken (time of each dose and how much). The list gives camps and caregivers the dose schedule they may need to supervise and gives emergency staff the current regimen. Keep it in line with the current prescriptions.
Record triggers, important medical history, allergies, epilepsy surgery (type, date, side effects), device (VNS, RNS or DBS) with date implanted, diet therapy (ketogenic, low glycemic, modified Atkins or other) and special instructions. These fields round out the picture for anyone treating the person in an emergency.
List the epilepsy provider, primary care, preferred hospital and pharmacy with phone numbers. The plan closes with 'My signature' for the patient or parent and 'Provider Signature' for the clinician, each dated. The provider's signature is what turns the rescue therapy lines into orders a caregiver can follow.
Download the current version from the source each time; forms change without notice.
Seizure Action Plan
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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The treating health care provider completes it together with the patient or parent. The provider supplies the seizure descriptions, rescue therapy orders and daily medicines and signs the Provider Signature line; the patient or parent adds contacts and signs the 'My signature' line. The family then shares it with whoever may need to respond.
The Epilepsy Foundation offers the general plan in English and Spanish as fillable PDFs, plus Simplified Chinese, Korean, Tagalog, Vietnamese, Ukrainian and French. A matching language version lets a family member or caregiver who reads another language follow the same first aid and rescue steps the provider set.
Yes. Page 2 has checkboxes for VNS, RNS and DBS with a date implanted, and the first aid list on page 1 includes 'Swipe magnet for VNS.' The same page records epilepsy surgery with type, date and side effects, and diet therapy such as ketogenic, low glycemic or modified Atkins.
For school, the Epilepsy Foundation's School Seizure Action Plan is the better fit: it adds a parent or guardian contact, a protocol for seizures during school, and a box to contact the school nurse. The general plan is written for home, camp, work and other caregivers, with emergency contact notification instead.