Holly Area School District
Allergy/Anaphylaxis Care Plan
Student Name: ____________________________________________________ DOB: ___________________
Teacher: _______________________________________ School Building: ___________________________
ALLERGY: (Check appropriate box and list specific allergen)
[] Foods: ___________________________________________________________________________________________
[] Latex: [] Type I; anaphylaxis [] Type IV; contact dermatitis
[] Stinging insects: _______________________________________________________________________________
[] Other: ___________________________________________________________________________________________
*HISTORY OF ASTHMA: [] YES [] NO (If yes, higher risk for severe reaction)
TO BE COMPLETED BY PHYSICIAN OR AUTHORIZED PRESCRIBER
[] IF ALLERGEN IS INGESTED, GIVE EPI-PEN IMMEDIATELY AND CALL 911
For Minor Reactions
Symptoms: ____________________________________________________________________________________________
Give Antihistamine: [] Diphenhydramine (Benadryl) [] Other: ___________________________________
Dose: _____________ [] Liquid [] Fast-melt [] Tablet [] Other: _____________Route: _________________
 Contact the parent/guardian.
 Stay with student to observe for more serious symptoms.
 Be prepared to give Epi-Pen.
*Any student suspected to have been exposed to the known allergen(s) listed
above, requiring Benadryl and/or having a minor reaction, should not
participate in any physical activity for a minimum of 2 hours after exposure
occurs. This includes but is not limited to; gym, recess, sports.
For Major Reactions
Symptoms: ____________________________________________________________________________________________
Give Epinephrine: Dose: ____________ Route: ___________
 Give Epinephrine immediately (Press hard against outer thigh, through
clothing if necessary until click. Hold in place for 10 seconds)
 CALL 911 immediately. (Always call 911 when Epinephrine is given)
 Contact parent/guardian. School personnel should accompany student to the
hospital if no parent/guardian available.
 If symptoms worsen, prepare to do CPR
[] This medication must be carried on the student’s person at all times.
[] This medication must accompany student on the bus.
[] This medication must accompany student for school related extracurricular events such
as field trips, sports, clubs, etc.
The student is both capable and responsible for self-administering of this medication:
[] Yes, supervised [] Yes, unsupervised [] No
Prescriber’s Name & Credentials: __________________________________________Date: __________________
*Prescriber’s Signature: _________________________________________ Phone #: _________________________
Rev. October, 2015
Holly Area School District
Allergy/Anaphylaxis Care Plan
Student Name: ____________________________________________________ DOB: ___________________
Teacher: _______________________________________ School Building: ___________________________
SYMPTOMS OF AN ALLERGIC REACTION THAT CAN PROGESS AND BECOME LIFE
THREATENING REQUIRING IMMEDIATE USE OF EPI-PEN:
 Itching and hives spreading over the face and body.
 Wheezing, difficulty swallowing/shortness of breathe.
 Swelling, itching, or tingling of face, tongue, lips, or neck.
 Vomiting or abdominal pain
SIGNS OF SHOCK: EXTREME PALENESS, CLAMMY SKIN, FEAR, APPREHENSION,
FATIGUE, CHILLS, LOSS OF CONSCIOUSNESS
TO BE COMPLETED BY PARENT/GUARDIAN
Please provide emergency information and relationship to the student.
Contact # 1: _____________________________________________ Phone #: __________________________
Contact # 2: _____________________________________________ Phone #: __________________________
Contact # 3: _____________________________________________ Phone #: __________________________
Preferred Hospital: __________________________________________________________________________
*In the event of an allergic/anaphylactic reaction, I agree to the emergency care plan
established by my child’s Authorized Prescriber, and I agree to release the school district and its
personnel from all claims of liability if my child suffers any adverse reactions. I also agree to
furnish the correct medications to the school in accordance with this care plan. I understand
that by signing this document, I give permission for my child’s Authorized Prescriber to share
information about the prescribed medications and/or allergic conditions listed here.
Parent/Guardian Name: ___________________________________________ Date: __________________
*Parent/Guardian Signature: _______________________________________________________________
Fax this signed care-plan to: ______________________: Attention School Nurse.
There MUST be one Medication Authorization Form filled out for each medication
prescribed.
Please provide an extra set of medications, labeled properly and not expired; to be kept in
the school office for back up purposes.
* The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school
nurses, physicians, or other health care providers for treatment purposes, without the authorization of the
student or student’s parent. For example, a student’s primary care physician may discuss the student’s
medication and other health care needs with a school nurse who will administer the student’s medication
and provide care to the student while the student is at school. See 45 CFR 164.512(b)(1)(vi). Updated
9/19/13 http://www.hhs.gov/ocr/privacy/hipaa/faq/ferpa_and_hipaa/517.html
Rev. October, 2015