Student’s Name:	DOB:  		ID# 		
School:	Teacher:  		Grade: 		
Extremely allergic to the following :  		
□ give epinephrine immediately for ANY symptoms of exposure.	
□ give epinephrine immediately after confirmed exposure, even if no symptoms are noted.	
□ Yes   □ No  Student also has asthma and is at increased risk of severe reaction	
Any SEVERE SYMPTOMS after suspected or known ingestion:		1. INJECT EPINEPHRINE IMMEDIATELY	
One or more of the following:			2. Call 911		
LUNG: Short of breath, wheeze, repetitive cough		3. Begin monitoring (see box below)	
HEART: Pale, blue, faint, weak pulse, dizzy, confused		4. Give additional medications:*	
THROAT: Tight, hoarse, trouble breathing/swallowing		-Antihistamine		
MOUTH: Obstructive swelling (tongue and/or lips)		-Inhaler (bronchodilator) if asthma	
SKIN: Many hives over body			*Antihistamines & inhalers/bronchodilators are not	
Or combination of symptoms from different body areas:		to be depended upon to treat a severe reaction.	
SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips)		USE EPINEPHRINE!	
GUT: Vomiting, diarrhea, crampy pain					
					
MILD SYMPTOMS ONLY:			1. GIVE ANTIHISTAMINE	
MOUTH: Itchy mouth			2. Stay with student; alert healthcare professionals	
SKIN: A few hives around mouth/face, mild itch		and parent		
GUT: Mild nausea/discomfort			3. If symptoms progress (see above), USE EPINEPHRINE	
4. Begin monitoring (see box below)	
	
Medications	Brand Name			Dosage	
Epinephrine					
Antihistamine					
Inhaler					
Other					

MONITORING					
Stay with student; alert healthcare professionals and parent. Tell rescue squad epinephrine was given;	
request an ambulance with epinephrine. Note time when epinephrine was administered.	
A second dose of epinephrine can be given five (5) minutes or more after the first if symptoms persist or recur. See back/attached	
for auto-injection technique. For a severe reaction, keeping student lying on back with legs raised.	
Treat student even if parents cannot be reached. Used Epinephrine cartridge should be given to EMS.	

REQUIRED SIGNATURES:					
SCHOOL MEDICATION CONSENT & HEALTH CARE PROVIDER ORDER	PARENT PERMISSION FOR MEDICATION		
CHECK ALL THAT APPLY:		   I give permission for school personnel to follow this plan, administer medication	
   Student instructed in proper use of their Epinephrine, and in my	   and care for my child and contact my provider if necessary. I assume full	
   opinion, CAN CARRY AND SELF-ADMINISTER Epinephrine AT SCHOOL.   ________	   responsibility for providing the school with prescribed medication and delivery/	
    Student should NOT carry Epinephrine while at school.   _____	_____	   monitoring devices. I approve this Allergy Action Plan for my child.	
    PARENT/GUARDIAN 	Date  	___	
    SCHOOL NURSE/DESIGNEE 	Date  	___	
MD/NP/PA SIGNATURE: 	DATE 		   OTHER 	    Date  _______		

EMERGENCY CONTACTS
Name	Relationship	Phone (1)	Phone (2)	

				

TRAINED STAFF MEMBERS

Name

Date

CC: □ Principal □ Cafeteria Mgr □ Bus Driver/Transportation □ Coach/PE □ Office Staff □ School Staff