8 allergy corrected lamp 09redone 1.27.10

Part 2: Life-Threatening Allergy Management Plan (LAMP)
To Be Completed By Health Care Provider Valid for Current School Year ________________
Name: ___________________________________ DOB: ___________________
Allergy to:

No *High risk for severe reaction □yes □ no Asthma Action Plan
It is medically necessary for student to carry epinephrine during school hours Yes No
Signs of an Allergic Reaction Include:

Itching and swelling of the lips tongue or mouth Itching and or a sense of tightness in the throat, hoarseness and hacking cough Hives, itchy rash and/or swelling about the face or extremities Nausea, abdominal cramps, vomiting, and/or diarrhea Shortness of breath, repetitive cough and/or wheezing *the severity of symptoms can quickly change. All the above symptoms can potentially progress to a life-threatening situation*
Action for a Minor Reaction:
1. If ingestion is suspected and/or symptom(s) are: minor itching “and/or” mild hives to skin give: Liquid Benadryl (or generic dephenhydramine) Dose:______________________
by mouth now and every 4-6 hours as needed.
2. Call Mother at _____________________ Father at _________________ or emergency contact.
3. Call Dr. _____________ at ___________________ to make physician aware of child’s reaction.

If condition worsens or does not improve within 10 minutes follow steps for MAJOR Reaction below:
Action for a Major Reaction:
1. If symptom(s) are large amount of hives, throat swelling, cough, difficulty breathing, wheezing,
vomiting, diarrhea or if symptoms progress after Benadryl is given, give:
-Epinephrine: inject intramuscularly: (check below)
Epipen® Epipen® Jr Twinject ™ 0.3mg Twinject ™ 0.15mg -Liquid Benadryl: dose: ____________ every 4-6 hours as needed (if able to tolerate liquids)
-Albuterol /or quick relief inhaler: 2 puffs with spacer now (IF asthmatic)
Give above now then call:


3. Repeat dose of Epinephrine if no improvement in 5-10 minutes

4. Call Mother at _____________________ Father at _________________ or emergency contact.

5. Call Dr. _____________ at _______________ to make physician aware of child’s reaction.
________________________ _________ _________________________ _________
Print MD Name: ___________________________________
Address: ___________________________________
Part 3: Life-Threatening Allergy Management Plan (LAMP)

Permission to Carry and/or Self-Administer Epinephrine (if appropriate)

Name: _________________________________ DOB: __________________________
I, as the Healthcare Provider, certify that this child has a medical history of severe allergic reactions has been
trained in the use of the prescribed medication(s) and is judged to be capable of carrying and self-administering this medication(s). The nurse or the appropriate school staff should be notified anytime the medication/injector is used. This child understands the hazards of sharing medications with others and has agreed to refrain from this practice. _________________________________ ________________________________ ____________ Healthcare Provider Signature Print Healthcare Provider name Date In accordance with the Code of Virginia Section 22.1-274, I agree to the following: I will not hold the school board or any of its employees liable for any negative outcome resulting from the self-administration of said emergency medication by the student. I understand that the school, after consultation with the parent(s) may impose reasonable limitations or restrictions upon a student’s possession and/or self-administration of said emergency medication relative to the age and maturity of the student or other relevant consideration. I understand that the school may withdraw permission to possess and self-administer the said emergency medication at any point during the school year if it is determined the student has abused the privilege of possession and self-administration or that the student is not safely and effectively self-administering the medication. _______________________________________ _______________________________________

Source: http://www.hampton.k12.va.us/departments/health/LifeThreateningAllergyMedical%20Plan.pdf


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