ALLERGY ACTION PLAN
Student Name: ________________D.O.B._______________ Grade ____ Teacher __________________
ALLERGY TO: ________________________________________________________________
Asthmatic:
Yes __________
NO __________ *high risk for severe reaction
SIGNS OF AN ALLERGIC REACTION INCLUDE:
Systems
Symptoms
MOUTH
THROAT
SKIN
GUT
LUNG
HEART
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 coughing, and/or wheezing
“thready” pulse, “passing out”
The severity of symptoms can quickly change. All above symptoms can potentially progress to a lifethreatening situation!
PLAN OF ACTION
1.
2.
3.
If systemic allergic reaction is suspected, give _________________________ IMMEDIATELY!
CALL 911
CALL: Parent/Guardian __________________________________________________________
4.
CALL: Dr. _____________________________________________________________________
If parent/guardian not available: EMERGENCY CONTACTS
1.
________________________________ Relation: _______________ Phone: _________________
2.
________________________________ Relation: _______________ Phone: _________________
DO NOT HESITIATE TO ADMINISTER MEDICATION AND CALL 911.
___This child has been trained in the use of the auto-injector and may be allowed to carry and use it
independently.
___This child should not use the auto-injector independently.
__________________________________
Physician Signature
___________________________
Date
__________________________________
Parent Signature
___________________________
Date
__________________________________
School Nurse Signature
___________________________
Date
Location of epinephrine auto-injector
1.________________________________
2.________________________________
11/15
Expires: _________________________
Expires: _________________________
ALLERGY ACTION PLAN for ______________________________ page 2
Parent Authorization for Delegation of Epinephrine Administration in the Absence
of the School Nurse
_____ In the absence of the school nurse, I consent to the administration of epinephrine
to my child by a school employee who has been trained to be a delegate. Delegates who
have been trained for my child are:
Delegate: ________________________
Delegate: _______________________
_____ I do not consent to the administration of epinephrine to my child by a delegate in
the absence of the school nurse.
____________________________
Parent Signature
____________________________________
Date
Parent Authorization for Self-Administration of Medication
I, the parent of ________________________, have submitted the Allergy Action Plan
form as determined by competent medical authority, thereby advising the Woodbury
Board of Education that my child has a life-threatening allergy. This illness does require
that he/she take medication. My son/daughter is capable of administering the medication
and has been instructed in the proper method of taking the medication by himself/herself.
I hereby authorize the Board of Education to allow my child to self-administer his/her
medication. I have been advised by the representatives of the Board of Education that the
Board shall not be responsible for any liability or resulting injury to my son/daughter
arising from the self-administration of medication. I hereby agree to indemnify and hold
harmless the Board of Education, its agents and/or employees from any liability relating
to or resulting from the self-administration by my child.
____________________________
Parent Signature
____________________________________
Date
Parent Release of Liability for Administration of Epinephrine by School Personnel
I, the parent of ____________________, hereby agree to indemnify and hold harmless
the Board of Education, its agents and/or employees from any liability relating to or
resulting from the administration of epinephrine to my child.
____________________________
Parent Signature
11/15
____________________________________
Date