Epi-pen with self administration form
SOUTH BRUNSWICK BOARD OF EDUCATION
Emergency Health Care Plan and Medication Orders for Life Threatening Allergies
Student Name: ___________________________________________________ Date of Birth: ______________________ School year: _______________________
School: _________________________________________________________ Grade: _________________ Unit/Teacher: _________________________________
: _____________________________________________________________________________________________ Asthmatic
: Yes / No___
STEP 1: TREATMENT – to be completed by Physician
Give Checked Medication
(to be determined by physician)
If exposure to an allergen occurs, but no symptoms
Mouth Itching, tingling, or swelling of lips, tongue, mouth
Skin Hives, itchy rash, swelling of the face or extremities
Gut Nausea, abdominal cramps, vomiting, diarrhea
Throat* Tightening of throat, hoarseness, hacking cough
Lungs* Shortness of breath, repetitive coughing, wheezing
Heart* Weak or thready pulse, low blood pressure, fainting, pale, blueness
If reaction is progressing (several of the above areas affected), give:
* Potentially life-threatening. The severity of symptoms can quickly change.
inject intramuscularly (circle one):
Epi-pen 0.3 mg
Epi-pen Jr. 0.15 mg _____________________________________________
give (medication/dose/route): _____Benadryl_______________mg__________________________________________________________________
Repeat Epi-Pen _____Yes_____/_____No_____ in 15 minutes if squad has not arrived - 2 kits will be needed in school.
STEP 2: EMERGENCY CALLS –
to be completed by Parent/Guardian
1. Call 911 for Rescue Squad and ask for Advanced Life Support -state that an allergic reaction has been treated.
Mother: Home: __________________________________ Work: __________________________________ Cell: ________________________________
Father: Home: ___________________________________Work: __________________________________ Cell: _______________________________
First: Name: __________________________________ Relationship: ______________________________ Number: _____________________________
Second: Name: ________________________________ Relationship: ______________________________ Number: _____________________________
3 Physician __________________________________________________________________ Phone: __________________________________________________
4. Preferred Hospital ___________________________________________________________ Phone: ___________________________________________________
I understand and agree that my child/patient
requires the administration of epinephrine or a unit dose of benadryl in conjunction with
epinephrine when exposed to a specific
allergen and he/she is capable of self-administration of the medication. Yes / No .
I understand that the school nurse, when available, is responsible for emergency care to my child/patient
. In the absence of the school nurse, the nurse can designate and train
another staff member to administer one or two Epi-pens Yes / No_
. Benadryl can not be given by any designee.
I understand that on a trip, my child/patient
may carry their own Epi-pens and Benadryl. Yes / No
BEFORE AND AFTER SCHOOL PROGRAM
This Emergency Plan and Medication Order may be used in the before and/or after school programs __ Yes
___ /___ No
___/__ Not applicable
I hereby acknowledge that the South Brunswick Board of Education, its agents and employees shall incur no liability as a result of any injury arising from the administrationof a pre-filled, single dose auto-injector mechanism containing epinephrine to my child, and agree to indemnify and hold harmless the district, its employees and its agentsagainst any claims arising out of the administration of a pre-filled, single dose, auto-injector mechanism containing epinephrine.
First Parent/Guardian (circle one)
Signature: ___________________________________________________________________ Date: _____________________
Second Parent/Guardian (circle one)
School Nurse’s Signature: ____________________________________________________________________________________ Date: ______________________
Physician’s Signature and Stamp
: __________________________________________________ Date: ____________________
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