Sample Fainting Episode Form
This sample form is intended to serve as a guide for stakeholders to create a form that aligns with the policies and procedures in their respective school division/school.
The Fainting Episode Form must be completed by the student’s parent/guardian and returned to the school administrator/designate.
As a result of a fainting episode, my child was seen by a medical doctor.
Results of Medical Examination
Physician’s input attached: