Emergency Plan of Action and
Medication Authorization: ALLERGIC REACTION
Student’s Name: ____________________________________Date of Birth:______________
School Health
Staff will place a
current picture of
your child here
Grade: ___ Homeroom Teacher: ______________ School Transportation: □ Bus □ Car □ Driver
School sports/Activities your child is involved in: ______________________________________________
ALLERGIC TO: _____________________________________________________________________________
Please list above only those foods/substances causing a serious allergic reaction in your child
My child cannot: □
touch □ eat/drink □ smell/inhale □ be bitten/stung by the above or
_______________________________________________
Does your child have an EpiPen? □ Yes □ No
Describe the type of reaction that will occur
THIS BOX TO BE COMPLETED BY SCHOOL HEALTH STAFF
□ EpiPen in Clinic □ Student to carry EpiPen □ Student to carry EpiPen + EpiPen in Clinic □ No Medication provided
If exposure to and/or ingestion of allergen occurs or is suspected, activate the following Emergency Plan of Action:
 Contact School Nurse immediately at EXT # _____________ AND Monitor student for symptoms (see chart below)
IF MILD SYMPTOMS, GIVE: □ Benadryl _________mg
Body System
Severe Symptoms
Mouth
□ Other ________________ ________mg
Mild Symptoms
Itchy Mouth
Itching and swelling of the lips, tongue, or mouth
Throat
Itching and/or a sense of tightness in the throat, hoarseness, hacking cough
Skin
Stomach
Hives, itchy rash, and/or swelling about the face or extremities
Few hives; Mild itch
Nausea, abdominal cramps, vomiting, and/or diarrhea
Mild nausea; discomfort
Lungs
Shortness of breath, repetitive coughing, and/or wheezing
Heart
Low and weak heart rate, “passing out”
IF SEVERE SYMPTOMS OCCUR AND STUDENT HAS EMERGENCY MEDICATION PROVIDED:
1. Give Emergency Medication: □ EpiPen
Dosage:
□ Other ____________
□ 0.15 mg □ 0.30 mg □ Other____
□ Intramuscular (upper thigh preferred) □ Other _________
DO NOT HESITATE TO ADMINISTER
MEDICATION AND CALL EMS FOR
ASSISTANCE!!!!
Route:
***If Nursing Staff present, and no medication provided, emergency stock medication may be administered per protocol***
2. Call EMS (911) immediately (if possible, have someone remain with student while EMS is called)
3. Notify Parent/guardian
4. Stay with student until EMS arrives; Offer reassurance; Continue to observe symptoms for change; Initiate CPR/First Aid if needed
5. If child needs to be transported via EMS, a parent/guardian or school representative will meet student at the hospital.
IF SEVERE SYMPTOMS OCCUR AND THERE IS NO EMERGENCY MEDICATION PROVIDED:
1. Call EMS (911) immediately (if possible, have someone remain with student while EMS is called)
2. Notify Parent/guardian
3. Stay with student until EMS arrives; Offer reassurance; Continue to observe symptoms for change; Initiate CPR/First Aid if needed
4. If child needs to be transported via EMS, a parent/guardian or school representative will meet student at the hospital.
I give permission for this Emergency Action Plan to be initiated for my child from this day forward and waive any liability on behalf of the school
and/or school staff. I understand that I have the ultimate responsibility for ensuring an ample, current supply of medication is kept at school for my
child. My signature will give permission for exchange of verbal and written communication between the physician and the school nurse/health staff
regarding my child’s medical regimen. I understand Emergency medications are administered only according to current prescription label and/or
physician ordered standing protocol for Bardstown City Schools. I understand this form will be shared with all staff that has contact with my child
while he/she is at school/school sponsored events in order to ensure my child’s safety and well being.
Signature of Parent/Guardian: ______________________________________Date ____________ School Nurse Initial: ______
Home phone: ________________Work phone ___________________ Cell Phone: __________________ Texts OK? □ Yes □ No
2013 Revision