Individual Anaphylaxis Management Plan
This plan is to be completed by First Aid on the basis of information from the student's medical practitioner
(ASCIA Action Plan for Anaphylaxis) provided by the parent.
It is the parents' responsibility to provide the College with a copy of the student's ASCIA Action Plan for
Anaphylaxis containing the Emergency Procedures Plan (signed by the student's Medical Practitioner) as well as
an auto adrenaline injector within its expiry date. Parents must also inform the College if their child's medical
condition changes.
Insert student
photo here
Student
DOB
Year Level
and
Homeroom
Severely allergic to:
Other health conditions
Medications at school
EMERGENCY CONTACT DETAILS (PARENT/CARER)
Name
Name
Relationship
Relationship
Home phone
Home phone
Work phone
Work phone
Mobile
Mobile
Address
Address
EMERGENCY CONTACT DETAILS (ALTERNATE)
Name
Name
Relationship
Relationship
Home phone
Home phone
Work phone
Work phone
Mobile
Mobile
Address
Address
Individual Anaphylaxis Management Plan
Page 1 of 5
May 2015
Medical practitioner
Name
contact
Emergency Medications
to be provided for school
e.g Ventolin, Claratyne,
Epipen
Storage for Adrenaline
Autoinjector
Phone
EPIPEN SUPPLIED BY PARENT
Primary Epipen: in students pencil case
Secondary Epipen, ACSIA action plan and management plan to be stored in First Aid
ENVIRONMENT
TO BE COMPLETED BY PARENT: Please consider each environment/area (on and off school site) the
student will be in for the year, e.g. classroom, canteen, food tech room, sports oval, excursions and camps
etc. (Initial where applicable and N/A where not applicable)
Name of environment/area: Classroom (and pertaining to all College activities)
Risk identified
Actions required to minimise the risk
Who is responsible
Initial /
N/A
Contact with
allergen
Identification of Students with anaphylaxis among
staff and in the Canteen
Encourage community to avoid bringing food
allergens to school or food sharing
Allergy students given isolated area and provided
with own utensils and alternate food requirements.
Potential allergens kept in their own packaging and
separate to other food sources.
Ensure all cooking utensils/dishes in food class are
thoroughly washed and cleaned
Individual Adrenaline Auto injector present for every
class
Use of non-food treats as rewards
First Aid Staff
All staff
Staff of food classes
Staff of food classes
Staff member
supervising that class
Student
All staff
Encourage College community to wash hands after All staff
eating
Canteen staff are able to demonstrate training in
Head Standards and
food allergen management and have training in
Accreditation
recognition and treatment of anaphylaxis
First Aid Staff
For special occasions, College staff should consult Staff member
parents in advance to either develop an alternative organising the activity
food menu or request the parents to send a meal for
Parents
the student.
Provision of up to date Individual Management Plan Parents
and ASCIA Action plan
Provision of medications required to treat
Parents, students
anaphylaxis e.g. antihistamines, adrenaline
autoinjector.
Provision of up to date medical information related Parents
to allergy and treatment
Individual Anaphylaxis Management Plan
Page 2 of 5
May 2015
Name of environment/area: School Yard and Special Events
Risk identified
Actions required to minimise the risk
Who is responsible
Initial /
N/A
Emergency
Up to date Anaphalaxis management plans
Response in
accessible to all staff on school grounds.
place to react to
incident
Sufficient staff on duty trained to recognise and
treat anaphylaxis
Principal
First Aid
Principal
First Aid staff
General Use adrenaline autoinjectors; in date and in First Aid Staff
various locations throughout the College
Name of environment/area: Out of school settings/ Outside school hours
Risk identified
Actions required to minimise the risk
Who is responsible
Initial /
N/A
Incidence of
anaphylaxis
occurring
Individual risk assessment for each student
attending who is at risk of anaphylaxis
Presence of staff sufficiently trained in current
anaphylaxis management to accompany student
Staff member
organising activity
Staff member
organising activity
Staff participating should be clear about the roles
and responsibilities in the event of an anaphylactic
reaction.
Use of non-food treats as rewards
Individual adrenaline autoinjector to be present on
student
Staff member
organising activity
Personal autoinjector, ASCIA plan and mobile
phone to be taken with staff
General Use adrenaline autoinjector present in the
first aid kit
Risk assessment undertaken for each student with
anaphylaxis attending
Identification by face of students diagnosed with
anaphylaxis attending by all staff attending
Contact with activity provider to ensure risk
minimisation and prevention strategies are in place,
ensuring they are able to provide food that is safe
for anaphylactic students
The camp cook to demonstrate satisfactory training
in food allergen management and its implications on
food handling practices, including avoiding use of
and stocking food allergens
Individual Anaphylaxis Management Plan
Page 3 of 5
All staff
Staff member
organising activity
Student
Staff member
organising activity
Staff member
organising activity
Staff organising activity
with parents as
necessary
Staff organising activity
Staff member
organising activity
Staff member
organising activity
May 2015
Name of environment/area: Interstate or Overseas Travel
Risk identified
Actions required to minimise the risk
Who is responsible
Initial /
N/A
Incidence of
anaphylaxis
occurring
Consultation with parents/carers well in advance
Staff member
organising activity
First Aid Staff as
necessary
Parents
Investigation of potential risks at all stages of the
Staff member
overseas travel and management of risks, identified organising activity in
and potential
consultation with
parents
Use of ASCIA Travel Plan to facilitate carriage of
Staff member
autoinjector
organising activity
First Aid Staff as
necessary
Parents
Re-assessment of College’s Emergency Response Staff member
Procedure and adaptation to circumstances of the organising activity
overseas trip
Name of environment/area: Work Experience
Risk identified
Actions required to minimise the risk
Who is responsible
Initial /
N/A
Incidence of
anaphylaxis
occurring
Involvement of parents, the student and the
employer in discussions regarding risk management
prior to a student at risk of anaphylaxis attending
work experience
Staff member
organising activity
Employer
Parents
Student
Employer must be shown the ASCIA Action Plan for Staff member
Anaphylaxis and how to use the adrenaline
organising activity
autoinjector in case the work experience student
Student
shows signs of an allergic reaction whilst at work
experience
*NOTE: Adrenaline autoinjectors are referred to as:
Primary. A student’s own adrenaline autoinjector and this is to be in the student’s possession at all times.
Secondary. A student’s own adrenaline autoinjector and this is to be kept in the First Aid for use by the individual
student.
General Use. Adrenaline autoinjectors that are purchased by the College and available to be used in an emergency
situation, in particular outside of normal school hours.
Individual Anaphylaxis Management Plan
Page 4 of 5
May 2015
CONFIRMATION AND ACKNOWLEDGEMENT
This Individual Anaphylaxis Management Plan will be reviewed on any of the following occurrences
(whichever happens earlier):

Annually;

If the student's medical condition, insofar as it relates to allergy and the potential for anaphylactic
reaction, changes;

As soon as practicable after the student has any anaphylactic reaction; and

When the student is to participate in an off-site activity, such as camps and excursions, or at special
events conducted, organised or attended by the College (e.g. class parties, elective subjects, cultural
days, incursions).
I have Acknowledge the development of this Individual Anaphylaxis Management Plan.
I consent to the risk minimisation strategies proposed.
Signature of parent:
Date:
I have consulted the relevant College staff who will be involved in the implementation of this Individual
Anaphylaxis Management Plan.
Signature of Principal (or nominee):
Date:
Individual Anaphylaxis Management Plan
Page 5 of 5
May 2015