File: JHCD-E
LEXINGTON CITY PUBLIC SCHOOLS
300 DIAMOND STREET, LEXINGTON, VIRGINIA 24450
Name of School: __________________________________ School Year: ___________________
MEDICATION PERMISSSION FORM - PRESCRIBED EPINEPHRINE – CONSENT FOR ADMINISTRATION
Student Name: _____________________________________________________________________________
PRESCRIBING PHYSICIAN:
This student may have a severe allergic reaction to
I have attached the required Food Allergy Action Plan which describes this student’s potential symptoms.
Yes
No
Any SEVERE SYMPTOMS after suspected or known
contact with allergen:
One or more of the following:
1. Heart rate greater than 120 times a minute, systolic blood
pressure less than 80.
2. Breathing rate less than 12 or greater than 36 times a
minute.
3. Significant wheezing or poor air movement.
4. Overwhelming generalized hives or sudden onset of
swelling.
5. An anxious student or a student with decreased
consciousness.
6. Drooling, hoarse voice, and/or inability to swallow.
1. INJECT EPINEPHRINE IMMEDIATELY
2. Call 911
3. Begin monitoring student: Stay with student,
have parent notified, continuing symptoms,
what time was epinephrine given
4. Give additional medications:
- Antihistamine
- Inhaler if asthmatic
MILD SYMTPOMS:
1. Few hives, mild itch
2. Mild nausea/discomfort
1. GIVE ANTIHISTAMINE
2. Stay with student; alert parent
3. If symptoms progress as above USE
EPINEPHRINE
4. Begin monitoring as above
It is necessary for him/her to carry an Epi-Pen with them during the school day, during activities, and in transit to and
from school.
Yes
No
The student knows how to use the injectable and has demonstrated the ability to administer
Yes
No
Medications Prescribed: Epinephrine ___________________________________________________________________
Antihistamine _________________________________________________________________
Other (e.g., inhaler) _____________________________________________________________
_____________________________________________________
Physician Signature
PARENT:
_______________________________________
Date
I am in agreement with this plan of care, and I give permission for the school to follow this. I understand that the principal
may rescind this privilege if my child fails to handle the medication safely and appropriately.
Epi-Pen to be kept with student
Epi-Pen to be kept in office
Epi-Pen to be kept with teacher
Parent/Guardian Signature
LEXINGTON CITY PUBLIC SCHOOLS
Date