Report for the Emergency Administration of Albuterol
Name of County:
*
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
DeKalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
LaPorte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
Scott
Shelby
Spencer
St. Joseph
Starke
Steuben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
Date of Albuterol Administration:
*
-
Month
-
Day
Year
Date Picker Icon
Type of Person Emergency Medication Given to
*
Student
Staff
Visitor
Albuterol Administered By
*
RN
LPN
Health Aide
Non-licensed School Personnel
Self-administered by Person
Other
Albuterol Was
*
Student’s Own Albuterol Provided to the School by the Parent
Staff or Visitor’s Own Albuterol
Stock Albuterol Provided by the School
Title of Person Completing Form
*
RN
LPN
Health Aide
Non-licensed School Personnel
Other
Submit
Should be Empty: