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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: _________________________________ Allergy to: _____________________________________________________________________________________________ Asthmatic: Yes / No___
STEP 1: TREATMENT – to be completed by Physician
Symptoms:
Give Checked Medication
(to be determined by physician)
If exposure to an allergen occurs, but no symptoms Epinephrine
Antihistamine
 Mouth Itching, tingling, or swelling of lips, tongue, mouth Epinephrine
Antihistamine
 Skin Hives, itchy rash, swelling of the face or extremities Epinephrine
Antihistamine
 Gut Nausea, abdominal cramps, vomiting, diarrhea Epinephrine
Antihistamine
 Throat* Tightening of throat, hoarseness, hacking cough Epinephrine
Antihistamine
 Lungs* Shortness of breath, repetitive coughing, wheezing Epinephrine
Antihistamine
 Heart* Weak or thready pulse, low blood pressure, fainting, pale, blueness Epinephrine
Antihistamine
 Other* ___________________________________________________ Epinephrine
Antihistamine
 If reaction is progressing (several of the above areas affected), give: Epinephrine
Antihistamine
* Potentially life-threatening. The severity of symptoms can quickly change.
Epinephrine - inject intramuscularly (circle one):
Epi-pen 0.3 mg
Epi-pen Jr. 0.15 mg _____________________________________________
Antihistamine - 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: ___________________________________________________ SELF ADMINISTRATION
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 .
DESIGNEES
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.
CARRYING MEDICATION
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) Signature: _________________________________________________________________ Date: _____________________
School Nurse’s Signature: ____________________________________________________________________________________ Date: ______________________ Physician’s Signature and Stamp: __________________________________________________ Date: ____________________

Source: http://www.sbschools.org/our_schools/programs/health/docs/epi-pen_with_self_administration.pdf