SOUTH PLAINFIELD BOARD OF EDUCATION
South Plainfield, New Jersey 07080
Policy
Picture Here
Emergency Health Care Plan
Life Threatening Allergies
Allergy to:
Student’s Name:
DOB:
Teacher:
School Year:
Signs of an allergic reaction include (previous reactions, if any):
Systems
Mouth
Throat
Skin
Gut
Lung
Heart
Symptoms
itching and swelling of the lips, tongue or mouth
itching and/or 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 life-threatening situation!
Action:
1. If ingestion or contact occurs, immediately give
2. Call 911 & request MICU. If MICU has not arrived within 15 minutes:
3. Repeat EPIPEN – YES or NO (circle one)
4. Call:
Mother (name)
H#
C#
Father (name)
H#
C#
5. Call: Doctor
@ #
(Med & dose)
(Drs. Order)
W#
W#
Preferred Hospital:
DO NOT HESITATE TO ADMINISTER MEDICATION OR CALL RESCUE SQUAD
Parent Signature
Date
Doctor Signature
Date
Nurse Signature
Date
School Doctor Signature
Date
Emergency Contact:
1. Name:
Relation:
2. Name
Relation:
Trained Staff Members:
1.
Room#
2.
Room#
Phone#
Phone#