The New York State Department of Health's one-page asthma action plan, dated 5/17, lets a health care provider write out daily controller and quick-relief medicines by green, yellow and red zone, list triggers and record asthma severity. Its permissions section authorizes medication use at school and, optionally, lets a student carry and use a rescue inhaler independently.
The patient's health care provider completes the zones, severity and triggers and signs the school permission for a stated school year. A parent or guardian signs consent for the school nurse to give the medicines, and both sign if independent carry is approved.
Download the current version from the source each time; forms change without notice.
Asthma Action Plan
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. NYSDOH posts the plan in Spanish (Publication 4851) and in Chinese, Haitian Creole, Italian, Korean, Russian, Yiddish, Polish, French, Bengali, Arabic and Urdu. Most NYSDOH asthma materials, including the action plan, can be ordered free through its publication catalog.
The provider writes the start and end of the school year the plan is valid for and signs it. The parent's signature consents to the school nurse giving the medicines, or trained staff helping after nurse review, and the plan is shared with school staff caring for the child.
Only if the optional independent carry section is signed. The provider attests that the student has demonstrated effective self-administration of the rescue medicine and may carry and use it without supervision, and the parent or guardian signs a matching agreement.