Microsoft word - authorization_for_management_of_an_allergic_reaction_3-05.doc

FREDERICK COUNTY PUBLIC SCHOOLS/FREDERICK COUNTY HEALTH DEPARTMENT
AUTHORIZATION FOR MANAGEMENT OF AN ALLERGIC REACTION
This order is valid only for the current school year_____________________ (Including Summer Session)
Emergency injections are usually administered by non-health professionals such as, a FCPS employee or a FCHD health room technician. These persons are trained by
a school registered nurse to give the injection. 911 will be called while the student, health services staff or school staff administers the EPIPEN.
Prescription medication must be in a container labeled by the pharmacist or health care provider. Over-the-counter medication must be in the original unopened container with the label intact.
The provider will be called if a question arises about the student and their medication. Thoroughly review reverse side of form before completion. HEALTH CARE PROVIDER AUTHORIZATION
Type of Medication/Dosage/Route of Administration: Check appropriate box (es)
Benadryl Elixir 12.5 mg P.O.* Benadryl Elixir 25 mg P.O. Benadryl Elixir ____ mg P.O.
EPIPEN 0.15 mg IM** EPIPEN 0.3 mg IM *P.O. – by mouth **IM - Intramuscularly
Medication is to be Administered: Check appropriate box (es)
Immediately after insect sting (bee, wasp, hornet, yellow jacket) Immediately after the ingestion of (specify):______________________________________________________________ Immediately after contact with (specify): __________________________________________________________________ Unknown etiology: ___________________________________________________________________________________ If Benadryl and EPIPEN Are Ordered: Check appropriate box
Give Benadryl and EPIPEN at the same time. Give Benadryl, and then wait ____ minutes, if you see (specify specific signs and symptoms i.e. audible wheezing, heart rate above ___, tongue swelling, etc.) _________________________________________________________________
then give EPIPEN.

Repeat EPIPEN dose in 15 minutes if EMS has not arrived** Yes No
**For a repeat dose, box must be checked above and parent must provide second EPIPEN for school.
Possible Medication Side Effects:
EPIPEN: palpitations, rapid heart rate, sweating, nausea and vomiting
Benadryl: drowsiness, sedation, sleepiness, dizziness, restlessness, hypotension, palpitations
Comments: _________________________________________________________________________________________
Health Care Provider’s Name/Title: (Type or Print) Use for Health Care Provider’s Address Stamp PARENT/GUARDIAN AUTHORIZATION
I request designated personnel to administer the medication as prescribed by the health care provider above. I certify that I have legal authority to consent to the administration of medication at school. Parent/Guardian Signature: SELF-CARRY/SELF-ADMINISTRATION AUTHORIZATION/APPROVAL
Self-carry and/or self-administration of prescribed medication must be authorized by the provider and approved by the school registered nurse. Health Care Provider’s authorization for: Self-Carry Yes No Self-Administration: Yes No Self-Carry: Yes No Self-Administration: Yes No Order reviewed and signed by school registered nurse: R:\School Health\CLINICAL FILE DRAWER\Medication and Treatment- Forms & Letters\EpiPen Information\Auth Form.3/05 IMPORTANT INFORMATION FOR PARENTS/GUARDIANS AND PHYSICIANS
1. An acute allergic reaction can be a life-threatening situation. Completion of this form in its entirety is vital so that the EPIPEN can be administered and emergency care implemented. 2. If the student experiences an acute allergic reaction, FCPS personnel will dial 911 while the student/FCHD school health employees/or FCPS staff administers the EPIPEN. Parent/guardian will be notified. 3. An EPIPEN sent to school, must be labeled by a registered pharmacist with the name of the medication, the dose, the name of the health care prescriber, the name of the student, and directions for administration. 4. The parent/guardian should note the expiration date and provide a new EPIPEN prior to 5. The FCHD school health employees must review and approve these forms in the school prior 6. The parent/guardian, health care prescriber and school RN must indicate on the reverse side of this form whether the pupil is capable of self-administering the EPIPEN, if needed. R:\School Health\CLINICAL FILE DRAWER\Medication and Treatment- Forms & Letters\EpiPen Information\Auth Form.3/05

Source: http://eteamz.active.com/uhsmd/files/Authorization_for_Management_of_an_Allergic_Reaction.pdf