Epi-Pen Self-Carry Plan/Form - Indian Hill School District

Indian Hill Exempted Village School DistrictAuto-injector (Epi-pen) Self-carry PlanTo provide the best care for our students, two options are available for administration ofan auto-injector (Epi-pen) for students with serious and/or life-threatening food allergies.Option #1After parent and physician complete the appropriate medication authorizationform, and provide the nurse/health specialist with the prescribed (auto-injector) Epi-pen,the student comes to the building clinic where the auto-injector (Epi-pen) is kept to havethe medication administered under supervision. The objective of this option is to insurethat an allergic reaction is taking place, that the medication will be used correctly, in theproper amount, and the time of use will be documented. This also insures that follow-upcare is provided.Option #2Qualified students that meet or exceed the requirements listed below will beallowed to carry and use an auto-injectors ( Epi-pens). The objectives of this option areimmediate accessibility and facilitation of self-responsibility for medication use.A qualified student is one who has:Completed the Medication Procedure/Student Assessment Form (thatallows carrying and self-medication with an auto-injector for students withlife-threatening food allergies signed by parent, student, physician, andnurse/health specialist).Demonstrated correct use of the auto-injector.Agreed to never share the auto-injector with anyone.Agreed to keep the auto-injector in the agreed upon designated area.Agreed to contact an adult to inform them of the allergic reaction prior tousing the auto-injector. This will insure that the building nurse/healthspecialist will be able to provide care and follow-up treatment.Medication Procedure That Allows Carrying And Self-Medication With An Autoinjector(Epi-pen) For Students With Serious Food AllergiesParent, Student, Physician and Nurse/Health Specialist Must SignStudent Information (to be filled out and signed by parent/guardian)Date__________________________________________Student’s Name ________________________________ Grade_____ DOB__________School Year__________ Teacher’s Name (if applicable) _________________________Parent/Guardian Name______________________________ Home Phone ___________Address_________________________________ Cell#__________ Work#___________Emergency Contact ____________________________ Phone _____________________Physician (for food allergy) ___________________________ Phone________________Hospital Preference (for emergency) __________________________________________1. What is your child’s food allergy?_________________________________________

2. Has your child had a reaction to a food or was he/she diagnosed after a skintest?_____________________________________________________________3. If they have experienced a reaction in the past, what reaction did your childexperience? (include any aura before physical signs)____________________________________________________________4. Has your child been hospitalized for a food allergy reaction? ________________5. Has your child ever had to use epinephrine for an allergic reaction? ___________6. List any other medical conditions your child presentlyhas.______________________________________________________________7. List any medications your child presentlytakes._____________________________________________________________Student Action Plan (for students carrying auto-injectors (Epi-pens)The following are signs of an allergic reaction:Mouth – ITCHING AND SWELLING OF LIPS, TONGUE OR MOUTHThroat – ITCHING AND/OR SENSE OF TIGHTNESS IN THE THROAT,HOARSENESS AND COUGHSkin – HIVES, ITCHY RASH, AND /OR SWELLING ABOUT THE FACE OFEXTREMITIESGut - NAUSEA, ABDOMINAL CRAMPS, VOMITING, AND/OR DIARRHEALungs – SHORTNESS OF BREATH, REPETITIVE COUGHING AND/ORWHEEZINGHeart – THREADY PULSE, LOSS OF CONSCIOUSNESSGeneral – LETHARGY, WEAKNESS** A sense of foreboding, fear or apprehension often precedes an allergic reaction.Take the following action if any of the above signs appear.1. The student will notify a supervising adult to contact the building nurse/healthspecialist that an allergic reaction to food is occurring. Be sure to clearly statename.2. Have supervising adult accompany student to the designated location of the autoinjector(Epi-pen).3. Administer the auto-injector (Epi-pen) per instructions and stay at the locationuntil the nurse arrives.4. Nurse will perform an emergency assessment.5. 911 will be called. The nurse will stay with the student until EMS arrives.6. The nurse will notify the office staff to contact parent to arrange to meet EMS atschool or hospital.7. Auto-injector (Epi-pen) will be disposed of per universal precautions.8. If the reaction occurs in the classroom, the teacher will reassure other studentsthat the classmate is being cared for appropriately.9. Nurse will document incident and contact parents for follow-up care.Field Trip Action Plan1. The student will notify a supervising adult that an allergic reaction to food isoccurring and they are carrying an auto-injector (Epi-pen) and have permission touse it. (Teachers will be carrying all student Emergency cards and have priorknowledge of students with food allergies and those who have self-carry plans).

2. The adult will stay with the student during the administration of the auto-injector(Epi-pen).3. 911 will be called. * FYI - All buses have phones.4. Parents will be contacted and arrangements will be made to meet EMS at thedesignated hospital.5. Teacher will give auto-injector (Epi-pen) to EMS personnel for disposal.6. Teacher will reassure other students on the field trip that their classmate is beingcared for appropriately.7. Teacher will notify the building nurse/health specialist of the incident.8. Nurse will notify parents for follow-up. The incident is to be documented in thestudent’s health file.During Bus Transportation.1. The student will notify the bus driver that an allergic reaction to food is occurringand he/she has an auto-injector (Epi-pen) and has permission to use it. (Busdrivers will have prior knowledge of students with food allergies and those whohave self-carry plans.2. The bus driver will pull to the side of the road.3. While the student is administering the auto injector, the bus driver will notify 911and inform EMS of the location of the bus. If auto injector used, the syringe willbe given to EMS for disposal.4. Notify the transportation office of the situation. Transportation will notify theparents and arrangements will be made to meet EMS at the designated hospital.5. Transportation will notify the building nurse/health specialist of the incident.6. Nurse will notify the parents for follow-up. The incident is to be documented inthe student’s health file.Extracurricular Activities1. The student will notify the coach, director, teacher or supervising adult that anallergic reaction is occurring and he/she has an auto-injector ( Epi-pen) and haspermission to use it.2. The adult will stay with the student during the administration of the auto-injector.3. 911 will be called and the adult will inform EMS of the location of the activity.4. Parents will be notified and arrangements will be made to meet EMS at thedesignated hospital.The auto injector (Epi-pen) will be carried (designated area) _______________________*Additional Information________________________________________________________________________________________________________________________________________________**Parent or student should notify the school nurse/health specialist if any information onthe student’s condition changes during the school year.*** Parents/Guardian relinquish the Indian Hill Exempted Village School District of allliability related to the misuse of the auto-injector by their child, other students and/ornon-medical district personnel.

I give my permission for my child ____________________________________________to carry his/her auto injector (Epi-pen) at school. I understand that he/she must followthe rules required for self-medication with an auto injector at school:Demonstration of correct use of auto injectorAgree to never share auto injector with anyoneAgree to keep auto injector in designated areaAgree to contact supervising adult when allergic reaction occurs, prior toadministering auto injector.Parent/Guardian Signature __________________________________ Date ___________Assessment of Student’s Knowledge of and Responsibility for Control of FoodAllergy Reaction(interview to be done by school nurse/health specialist)1. What food are you allergic to?___________________________________________2. Have you ever had an allergic reaction to this food? _______________________3. If so, what reaction did you have? _____________________________________4. When was your last reaction? _________________________________________5. Do you know what causes this to happen? _______________________________6. Have you ever used an auto injector (Epi-pen)? ___________________________7. Do you want to carry your own auto injector? ____________________________8. Why? ____________________________________________________________A. Student has demonstrated to the nurse/health specialist the correct use of theauto injector (Epi-pen). _______________B. Student agrees never to share auto injector with anyone. ___________C. Student determines where to store auto injector. Location is__________________(Staff will be made aware of the location)D. Student agrees to contact supervising adult at the onset of an allergicreaction. ___________Student’s Signature ______________________________________ Date _____________Nurse/ Health Specialist Signature __________________________ Date _____________Physician Approval for Student to Carry and Use Auto injector (Epi-pen)In order for a student to possess and use an auto injector (Epi-pen) for an allergic reactionto food he/she must have written approval from the student’s physician as well as the

parents or guardian. The student must demonstrate to the school nurse/health specialistthe appropriate use of the auto injector. Signed approvals will be kept in the buildingclinic.Physician (please attach orders or fill out the following and sign)Name of student __________________________________________________________Address of student ________________________________________________________Name of medication to be carried and used. ____________________________________Date for self-carry orders to begin. ___________________________________________Any special instructions?________________________________________________________________________________________________________________________________________________Physician’s signature _________________________________ Date ________________Physician’s phone number __________________________________________________KC/08