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school year unless renewed and initialed by provider. EMERGENCY ALLERGY PLAN: FOOD OR INSECT
AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINE BY SCHOOL/DAYCARE/CAMP PERSONNEL Connecticut State Law and Regulations 10‐212(a) require a written medication order of an authorized prescriber, (physician, dentist, advanced practice registered nurse or physician's assistant) and parent/guardian written authorization, for the nurse, or in the absence of the nurse, a designated principal or teacher to administer medication. Medications must be in the original properly labeled container and dispensed by a physician/pharmacist. Student Name _______________________________________________________DOB___________________________ History of Asthma __Yes __No Home Phone_________________________________Work Phone___________________________Cell_____________________________Grade________________ Health Care Provider Name(s)___________________________________________________________ Phone___________________________________________  Notify provider if treatment received
Administer bronchodilator after Epi‐Pen if student has a history of asthma
Potential Life-Threatening
Call 911 for ED evaluation if Epi‐Pen administered
Allergen(s)

ANAPHYLAXIS MANAGEMENT

IF STUDENT INGESTS / IS STUNG OR IS THOUGHT TO HAVE BEEN EXPOSED TO THE FOLLOWING:
25mg 50mg Do not Administer Benadryl 2. Notify Parent of exposure/potential exposure
3. Observe student for symptoms of Anaphylaxis*
4. Administer Epi Pen IM for any symptoms of Anaphylaxis
Prescriber authorization to self‐administer Yes No 5. Call Emergency Services if Epinephrine administered (911) Other:_____________________________________________________________________ ORAL ALLERGY SYNDROME (OAS) MANAGEMENT
Known Oral Allergy
F STUDENT INGESTS OR IS THOUGHT TO HAVE BEEN EXPOSED TO THE FOLLOWING & SYMPTOMS
Syndrome Allergen(s)
ARE LIMITED TO THE LIPS, MOUTH, AND TONGUE:
50mg Do not Administer Benadryl Other:_____________________________________________________________________ 2. Observe student for progressing symptoms of Anaphylaxis*
3. Administer Epi Pen IM for any additional symptoms of Anaphylaxis Jr Adult
Prescriber authorization to self‐administer ___________________________________________________________________________ Date Renewed/Initials_____________ Health Care Provider Signature
Date Date Renewed/Initials_____________ ___________________________
Stamp or Printed Name
Parent/Guardian:
Parent/Guardian:
I have reviewed and agree with the above protocol. I authorize communication between the Authorization to self‐administer medication: prescribing health care provider and school necessary for the safe implementation of this treatment ______________________________________________________________________________________________ _______________________________________________ Parent/Guardian Signature Date
Parent/Guardian Signature Date
*Symptoms of LIFE‐THREATENING anaphylaxis:
Usually occurs within minutes, but may occur up to 2 hours after exposure Chest tightness, wheezing, cough, shortness of breath Difficulty swallowing, tightness in throat Dizziness, fainting, “feeling of impending doom”

Source: http://www.hopkins.edu/ftpimages/82/download/2013%20Authorization%20for%20Emergency%20Allergy.pdf

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Les médicaments ototoxiques Les médicaments ototoxiques sont des produits pharmaceutiques qui ont l'inconvénient de pouvoir léser les structures de l'oreille interne (atteinte cochléaire ou vestibulaire) ou du nerf auditif. Il n'y a jamais atteinte de l'oreille externe ni de l'oreille moyenne. Plus de 130 médicaments et produits chimiques ont été répertoriés comme étant ot

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