The American Lung Association's school-age asthma action plan pairs green, yellow and red zone instructions with the consents schools need: parent permission for staff to give the listed medicines, consent for provider and school nurse communication, and a school nurse attestation that the student can self-carry a quick-relief inhaler. The July 2025 edition includes SMART/MART dosing with ICS/formoterol, and page 2 shows inhaler and spacer technique.
The student's health care provider completes severity, triggers and the zone medicines and signs the Healthcare Provider line. The parent or guardian signs the medicine and communication consents, and the school nurse signs the self-carry attestation after the student demonstrates the skills.
Enter the student's name, school and date of birth, then check the severity classification: intermittent, mild persistent, moderate persistent or severe persistent. List the student's asthma triggers, record the date completed, and mark whether vaccinations are updated. A QR code on the form links to how-to videos for the family and school staff.
Symptoms: breathing is good, no cough or wheeze, can work and play, sleeps well at night. List each control medicine with how much and when to take it, and check Home and/or School. Do the same for quick-relief medicines. For SMART/MART, check ICS/formoterol and enter puffs with spacer within the printed daily maximum. The exercise-induced line directs quick-relief medicine 10 minutes before physical activity as instructed.
Symptoms: some problems breathing, cough, wheeze or tight chest, problems working or playing, waking at night. Enter the quick-relief medicine with how much and how often, printed as every 20 minutes for up to 1 hour or a nebulizer once, and note that green zone control medicines continue. SMART users take ICS/formoterol as the quick reliever. The form tells the student to expect improvement within 20 to 60 minutes and to follow the red zone if getting worse.
Symptoms: lots of problems breathing, cannot work or play, getting worse instead of better, medicine not helping, feeling very sick. Enter the quick-relief medicine to take now, the number of puffs and how often, including the SMART option. The form prints the danger signs that call for emergency services right away: trouble walking or talking due to shortness of breath, blue lips or fingernails, or still in the red zone after 15 minutes.
The parent or guardian checks two statements: permission for the school nurse or designated trained staff to give the listed medicines in school, and consent for communication between the prescribing provider or clinic, the school nurse, the school medical advisor or school-based health clinic providers for asthma management. Then name, date, phone number and signature.
The prescribing clinician prints a name, the date and a phone number and signs. This is the only clinician signature on the form; the self-carry attestation below it belongs to the school nurse. Review the medicine names, doses and Home and School checkboxes before signing, because the same signed page goes to the parent, the school nurse and the provider's office.
The school nurse attests that the student has demonstrated the skills to carry and self-administer the quick-relief inhaler, including when to tell an adult if symptoms do not improve after taking it, and adds name, date, phone number and signature. On this form, the nurse's attestation, not the provider's signature, documents that the student is ready to self-carry.
Page 2 is an illustrated nine-step guide: take the cap off the inhaler, shake it for 5 seconds, attach the spacer and remove its cap, breathe out all the way, close lips around the mouthpiece, press down, breathe in slowly and deeply, hold the breath for 10 seconds if possible, then rinse with water and spit. Wait 1 minute before another puff.
Download the current version from the source each time; forms change without notice.
My Asthma Action Plan for Home and School
Mi plan de acción de asma para el hogar y la escuela
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Sources for this guide
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Yes. The American Lung Association publishes the plan for home and school in Spanish as Mi plan de acción de asma para el hogar y la escuela, and also in Haitian Creole, Russian and Ukrainian. Its general asthma action plan is available in several languages, while the Home and Childcare version is English only.
The school nurse. The School Nurse box attests that the student has demonstrated the skills to carry and self-administer the quick-relief inhaler, including when to tell an adult if symptoms don't improve. The health care provider and the parent sign their own sections, but the self-carry attestation belongs to the nurse.
Each zone has an ICS/formoterol checkbox with a blank for puffs with spacer: as a control medicine in the green zone, and as the quick reliever in the yellow and red zones. The form prints daily maximums of 12 puffs for ages 12 and older and 8 puffs for ages 4 to 11.
Yes. The Healthcare Provider section asks for the prescribing clinician's name, date, phone number and signature. The parent or guardian signs consent for school staff to give the listed medicines and for communication between the provider and school, and the school nurse signs the self-carry attestation.