Diastat Administration Reporting Form

Following administration of Diastat to students or staff, please complete this Diastat Reporting Form. While not mandatory, completion of this form will allow the Center to monitor the incidence and details of Diastat use in schools. This information will be used to plan programs and training, create educational resources, and provide support to school health professionals in the care of students/staff.

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* 1. School District Name

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* 3. Type of School

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* 4. Level

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* 5. Date / Time

Date
Time

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* 6. Diastat given

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