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Microsoft word - asd student allergy plan form 2009 final word

STUDENT ALLERGY/ANAPHYLAXIS CARE PLAN
Student Name _____________________ D.O.B. _________ Teacher ______________ Student
School Nurse______________________________ Phone Number ___________________
Health Care Provider ____________________ Preferred Hospital __________________
History of Asthma No Yes (Higher risk for severe reaction)
ALLERGY: (check appropriate) TO BE COMPLETED BY HEALTH CARE PROVIDER ONLY
Medications (list)
Latex: Circle: Type I (anaphylaxis) Type IV (contact dermatitis)
Stinging
Other (list):
RECOGNITION AND TREATMENT: To be completed by Health
Give CHECKED Medication
Care Provider ONLY
If food ingested or contact with allergen occurs:
Itching, tingling, or swelling of lips, tongue, mouth Hives, itchy rash, swelling of the face or extremities Nausea, abdominal cramps, vomiting, diarrhea Tightening of throat, hoarseness, hacking cough Shortness of breath, repetitive coughing, wheezing Thready pulse, low BP, fainting, pale, blueness Disorientation, dizziness, loss of consciousness If reaction is progressing (several of the above areas affected), GIVE:
The severity of symptoms can quickly change. + Potentially life-threatening
DOSAGE: TO BE COMPLETED BY HEALTH CARE PROVIDER ONLY
Epinephrine: Inject into outer thigh 0.3 mg OR 0.15 mg
Antihistamine: Diphenhydramine (Benadryl®) mg (Liquid or Fastmelts). ONLY if able to swallow.
Epinephrine Auto Injector will be used for a severe asthma episode at school, this may be given in
addition to the student’s prescribed medication or if the student does not have access to their
prescribed medication.

 This child has received instruction in the proper use of the Auto-injector: EpiPen® or Twinject® (circle one). It is my professional opinion that this student SHOULD be allowed to carry and use the auto-injector
independently. The child knows when to request antihistamine and has been advised to inform a
responsible adult if the auto-injector is self-administered.
It is my professional opinion that this student SHOULD NOT carry the auto-injector.
This child has special needs and the following instructions apply:
Health Care Provider Signature ______________________ Phone: ______________ Date ________
ASD EMERGENCY PROTOCOL:
1. Call 911. State that an allergic reaction has been treated, and additional epinephrine may
be needed.
2. Call parents/guardian to notify of reaction, treatment and student's health status.
3. Treat for shock. Prepare to do CPR.
Rev 7/09
Form adapted from the Food Allergy Anaphylaxis Network, “Food Allergy Action Plan” & the Asthma and Allergy Foundation of America, Alaska Chapter

Side 2: To Be Completed by Parent/Guardian, Student and School
Allergy/Anaphylaxis Care Plan (continued) Student Name ________________________ D.O.B. _____________
PARENT/GUARDIAN AUTHORIZATIONS:
□ I want this allergy plan implemented for my child; I want my child to carry an auto-injector and I agree to
release the school district and school personnel from all claims of liability if my child suffers any adverse reactions from self-administration of an auto-injector. □ I want this plan implemented for my child and I do not want my child to self-administer epinephrine.
□ Parent is responsible for auto-injectors for before and after school activities (there is no nurse available).
EMERGENCY CONTACTS:
HOME # WORK # CELL #
PARENT/GUARDIAN
PARENT/GUARDIAN
I understand that submission of this form may require the Nurse to contact and receive
additional information from your health care provider regarding the allergic condition(s) and
the prescribed medication. My signature below provides authorization for this contact. I also
understand that a signature is mandatory for school acceptance of this form.
Parent/Guardian Signature:
________________________Phone:_____________ Date:_________
STUDENT AGREEMENT:
□ I have been trained in the use of my auto-injector and allergy medication and understand the signs and
symptoms for which they are given;
□ I agree to carry my auto-injector with me at all times;
□ I will notify a responsible adult (teacher, nurse, coach, noon duty, etc.) IMMEDIATELY when my auto-injector
(epinephrine) is used;
□ I will not share my medication with other students or leave my auto-injector unattended;
□ I will not use my allergy medications for any other use than what it is prescribed for.
Student Signature: __________________________________________ Date ________________
Approved by Nurse, Signature: __________________________ Date __________________
PREVENTION: Avoidance of allergen is crucial to prevent anaphylaxis.
Critical components to prevent life threatening reactions: √ Indicates activity completed by school staff
Encourage the use of Medic-Alert bracelets Notify nurse, teacher(s), front office and kitchen staff of known allergies Use non-latex gloves and eliminate powdered latex gloves in schools Ask parents to provide non-latex personal supplies for latex allergic students Post “Latex Reduced Environment” sign at entrance(s) of building Encourage a no-peanut zone in the school cafeteria STAFF MEMBERS TRAINED:
LOCATION/ROOM
TRAINED BY (RN only)
Rev 7/09
Form adapted from the Food Allergy Anaphylaxis Network, “Food Allergy Action Plan” & the Asthma and Allergy Foundation of America, Alaska Chapter

Source: http://classroom.brazosisd.net/users/0044/docs/anaphylaxis_actionplanb.pdf

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