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LIFE-THREATENING ALLERGY CARE PLAN/504
Student:__________________________________ Birth Date: ____________________ Grade:_____________
Does this student also have Asthma?
No
Yes (higher risk for severe reaction)
This student is extremely reactive to the following allergen(s):
THEREFORE:
If checked, give epinephrine immediately for any symptom if the allergen was likely eaten (or stung, if sting allergy)
If checked, give epinephrine immediately if the student has definitely been exposed, even if there are no symptoms.
For any SEVERE SYMPTOMS after a suspected or
known ingestion (or sting, if sting allergy):
One or more of the following:
LUNG:
Short of breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy, confused
THROAT: Tight, hoarse, trouble breathing/swallowing
MOUTH: Obstructive swelling (tongue and/or lips)
SKIN:
Many hives over body
Or combination of symptoms from different body areas:
SKIN:
Hives, itchy rashes, swelling (e.g., eyes, lips)
GUT:
Vomiting, diarrhea, crampy pain
FOR MILD SYMPTOMS ONLY:
MOUTH:
SKIN:
GUT:
Itchy mouth
A few hives around mouth/face mild itch
Mild nausea/discomfort
1. INJECT EPINEPHRINE
IMMEDIATELY
Note time given: __________
2. Call 911
3. Begin monitoring (see box below)
4. Give additional medications*
-Antihistamine
-Inhaler/bronchodilator for Asthma
*Antihistamines & inhalers/ bronchodilators
are not to be depended upon to treat a severe
reaction (anaphylaxis). USE EPINEPHRINE.
1. GIVE ANTIHISTAMINE
2. Stay with student: alert healthcare
professionals and parent
3. If symptoms progress (see above).
USE EPINEPHRINE
4. Begin monitoring (see box below)
Medications/Doses:
Epinephrine:
Antihistamines:
Epinephrine Jr. 0.15 mg
Epinephrine 0.3mg
Benedryl/Diphenhydramine 12.5mg/5ml ______tsp(s)
or
25mg_______tab(s)
OR __________________________________________________________________
*Liquid antihistamine would be preferable over tablets IF AVAILABLE
Other: (e.g. inhaler/bronchodilator if asthmatic)
Albuterol/Xopenex 2 puffs or _______________________
MONITORING: Stay with student. Alert healthcare professionals and parents
*Tell rescue squad epinephrine was given: request an ambulance with epinephrine.
*Note time when epinephrine was administered. A second dose can be given 5 minutes or more after the first if
Symptoms persist or recur.
*For a severe reaction, consider keeping student lying on back with legs raised.
*Treat student even if parents cannot be reached.
The severity of the reaction can change quickly. Past reactions do not predict future reactions
Student:
may
may not
keep medication on person and self-administer.
TRANSPORTATION:
HCP signature
HCP printed name
Date
TRANSPORTATION:
Will this student ride the school bus to or from school?
Yes
No
• If student takes school bus, transportation department will be alerted to the student's allergy.
• This student carries epinephrine on the bus:
Yes
No
• Epinephrine can be found in:
Backpack
On Person
Other _________________
• Please consider an leaving extra supply of medication for before/after school activities (ie. sports, band)
• Other (specify): ______________________________________________________________________
FIELP TRIP PROCEDURES: Epinephrine must accompany student during any off campus activity.
• If student does not have the epinephrine on the day of the trip, he/she cannot attend.
• Student should remain with the teacher or parent/guardian during the entire field trip.
• Staff members on trip must be trained on epinephrine and student health care plan (plan must be taken).
• Other (specify): _____________________________________________________________________
FOR FOOD ALLERGY ONLY:
CLASSROOM
Student is allowed to eat only the following foods:
Those in manufacturer's packaging with ingredients listed and determined allergen-safe by the
parent/guardian.
Middle school or high school student will be making his/her own decision.
Alternative snacks will be provided by parent/guardian to be kept in the classroom.
Parent/guardian should be advised of any planned parties as early as possible.
Classroom projects should be reviewed by the teaching staff to avoid specified allergens.
Other (specify): ___________________________________________________________________
CAFETERIA
NO Restriction in seating arrangement.
Student will sit at a specified table.
• Cafeteria staff will be alerted to the student's allergy.
•Other: __________________________________________________________________________
PARENT/GUARDIAN Contact Information: (Update your school office when contact information changes)
Name: __________________________ H: ________________ C: _______________ W: _______________
Name: __________________________ H: ________________ C: _______________ W: _______________
EMERGENCY CONTACTS (if unable to reach parent/guardian)
1. _________________________ Relationship: _________________ Phone: ______________________
2. _________________________
Relationship: _________________ Phone: ______________________
PARENT/GUARDIAN STATEMENT: I request this medication to be given as ordered by the licensed health
care provider. I give Health Services staff permission to communicate with the medical office about this
medication. I understand the medication will not necessarily be given by a school nurse (designated staff will be
trained and supervised). Medical/Medication information may be shared with school staff working with my
child and 911 staff, if they are called. All medication must come in its originally provided container with
instructions as noted above by the licensed health care provider.
•I request and authorize my child to carry and/or self-administer their medication.
Yes
No
Parent/Guardian Signature: _________________________________________ Date: ______________
School Nurse Signature: ___________________________________________
Date: ______________
Principle Signature (elf-carry/administer): _____________________________
Date: ______________
A copy of the Health Care Plan will be kept in the substitute folder and given to all staff members who
are involved with the student.