Student Photo ID
CLOVERLEAF LOCAL SCHOOLS
High School
Office: 330-302-0328
Fax: 330-302-0530
Middle School
Office: 330-302-0207
Fax: 330-302-0520
Elementary School
Office: 330-302-0103
Fax: 330-302-0080
Food Allergy: Emergency Action Plan
Student’s Name:
School/Grade:
Date of Birth:
Contact Teacher:
Parent/Guardian Name:
Phone (Family):
Address
Physician:
RN:
Emergency Number:
Emergency Number:
Emergency Number:
Allergy to:______________________________________________________________________________
Weight:________ lbs.
If you would prefer your child to self-carry their epinephrine autoinjector, both signatures are required below:
______________________This student received instruction in the use of the epinephrine autoinjector by a trained
(prescriber’s signature)
staff member. It is my recommendation that this student carry their epinephrine
autoinjector on them at all times. The parent will supply second dose to be stored in the
school’s clinic.
_____________________ As the parent/guardian of this student, I authorize my child to possess and use an
(parent/guardian signature) epipeneprhine autoinjector as prescribed, at the school and any activity, event or
Program sponsored by or in which the student’s school is a participant. My child will
notify a school employee immediately before or upon use. The school employee will then
request assistance from an EMS provider. I will provide a backup (second) dose to the
school clinic per Ohio Revised Code 3313.718.
1. Any SEVERE SYMPTOMS after suspected or known allergen ingested:
One or more of the following:
LUNG: Short of breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy, confused
THROAT: Tight, hoarse, trouble breathing/swallowing
MOUTH: Obstructive swelling (tongue and/or lips)
SKIN: Many hives over body
Or combination of symptoms from different body areas:
SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips)
GUT: Vomiting, diarrhea, crampy pain
Treatment:
1. INJECT EPINEPHRINE IMMEDIATELY
2. Call 911
3. Begin Monitoring
4. Give additional medications (if ordered)
a. antihistamine
b. Inhaler (bronchodilator) if asthma
2. MILD SYMPTOMS ONLY:
Treatment:
1. GIVE ANTIHISTAMINE
2.. If symptoms progress (see above), USE
EPINEPHRINE & BEGIN MONITORING
MOUTH: Itchy mouth
SKIN: A few hives around mouth/face, mild itch
GUT: Mild nausea/discomfort
Student’s Name & Grade: ___________________________________________________________________________
Date of Administration to Start & End: ________________________________________________________________
1, Epinephrine given IM (brand, strength and dose): _______________________________________________________
________ Given immediately if allergen was DEFINITELY ingested; even if no symptoms are noted
________ Given immediately if allergen was LIKELY ingested; even if no symptoms are noted
Adverse reactions/special instructions:___________________________________________________________________
2. Antihistamine given orally (brand, strength and dose):____________________________________________________
________ Given immediately if allergen was DEFINITELY ingested; even if no symptoms are noted
________ Given immediately if allergen was LIKELY ingested; even if no symptoms are noted
Adverse reactions/special instructions:___________________________________________________________________
3. Other medication (brand, strength and dose):___________________________________________________________
Route & Time: ___________________________________________________________________________________
Adverse reactions/special instructions:________________________________________________________________
This plan is subject to change but only with documentation from physician along with meeting with parents and
staff. This plan will be shared with all teachers, support staff and transportation that are involved with student’s
school day.
I am in agreement with this plan of care and understand it will be shared as needed with members of the school staff to safeguard and
promote the health of the student listed above while at school. I will notify the school immediately if the health status of the
student listed above changes, we change physicians, or there is a change or cancellation of the physicians orders.
Parent/Legal Guardian_____________________________________Date____________
Parent/Legal Guardian ____________________________________ Date____________
RN: ________________ __________________________________ Date____________
MEDICAL REVIEW
I have reviewed the attached Individual Emergency Action Plan (EAP) for ______________________________________ AND
________ I approve the EAP as written
________ I approve the EAP with the attached amendments
________ I do not approve of the EAP as written and a substitute orders are
attached.
Physician __________________________________________Date________________
Other Recommendations:
2015/FoodallergyEAP/dmd