Seizure Response Plan - Office of Disability Services
  1. Semester and Year(*)
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  2. Students Full Name(*)
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  3. Students Home Address
  4. Address Line 1(*)
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  5. Address Line 2
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    If applicable
  6. City(*)
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  7. State(*)
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  8. Zip(*)
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  9. TTU Residence Hall and Room Number
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    If applicable
  10. Home Phone(*)
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    xxx-xxx-xxxx
  11. Cell
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    xxx-xxx-xxxx
  12. Instructions specific to the medical condition causing seizures
  13. Type of Seizure Disorder(*)
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  14. Frequency(*)
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  15. Most Recent Emergency Episode (Ambulance, Paramedic, Hospitalization, etc)(*)
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  16. You know I will be having a seizure when: (*)
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  17. Steps that should be taken when I have a seizure:(*)
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  18. Emergency Contact Information
  19. Contacts Name (*)
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  20. Contacts Phone(*)
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    xxx-xxx-xxxx
  21. Emergency Contact #2
  22. Contacts Name
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  23. Contacts Phone
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    xxx-xxx-xxxx
  24. You have the option to meet/register with the Office of Disability Services to discuss additional accommodations/adjustments.

    I give Tennessee Tech University permission to release this information to the appropriate faculty, staff, or medical assistance, so that timely and appropriate assistance can be provided to me in the event of a seizure. I understand that faculty in whose classes I am registered as well as campus police may be provided with a copy of this information, and that it may be necessary to call outside medical assistance. I am aware that I may refuse such assistance or medical treatment after it has already arrived. I further understand that I am responsible for any expense that may be incurred as a result of medical treatment that has been called or provided for me. I release Tennessee Tech University, its employees, officers, and trustees, from all liability for injury or loss which may occur as a result of my seizure disorder.

  25. Initial For Students Electronic Signature(*)
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  26. Date(*)
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  27. Witness's Full Name(*)
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  28. Initial For Witness's Electronic Signature(*)
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  29. Date(*)
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  30. Submit
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