(District Keeps Epinephrine Premeasured Auto-Injection Devices on Hand)
Staff Training Procedures
Staff training procedures regarding food allergies and anaphylactic reactions will be held annually at the beginning of each school year and as needed for new employees. As per
Windsor’s Student Allergy Prevention and Response policy, the staff will be trained on:
 signs and symptoms of an allergic reaction
 the use of an Epi-Pen auto-injector
 allergy prevention awareness
 emergency response
Anaphylaxis refers to a severe allergic reaction. An allergic reaction is an immune system response to a substance that itself is not harmful but that the body interprets as being harmful. Allergic reactions range from mild to severe, even life-threatening. Foods that most commonly cause an allergic reaction are peanuts, tree nuts, shellfish, milk, wheat, soy, fish and eggs. These severe allergic reactions can occur within minutes of ingestion or a reaction can be delayed for up to two hours. At present there is no cure for food allergies and strict avoidance is the key to preventing reactions. Exposure may occur by eating the food or food contact.
MOUTH
THROAT
SIGNS OF AN ALLERGIC REACTION
Itching and swelling of the lips, tongue or mouth
Itching and/or sense of tightness in the throat, hoarseness, hacking cough, and swelling of tongue and throat.
SKIN
STOMACH
LUNG
HEART
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, one feels like passing out
The severity of symptoms can quickly change. All above symptoms can potentially progress to a life-threatening situation! If you notice ANY symptoms or if they are exposed, send or contact the nurse immediately.
* The bolded symptoms are the most common.
DIRECTIONS FOR ADMINISTERING EPIPEN AND EPIPEN JR.
1. Pull off activation cap.
2. Hold back tip near outer thigh (always apply to thigh).
3. Swing and jab firmly into outer thigh until auto-injector mechanism functions. Hold in place and count to 10. The Epi-Pen unit would then be removed and taken with you to the Emergency Room. Massage the injection area for 10 seconds.

1. Training is provided to staff on the signs and symptoms of a severe allergic reaction as provided in the student’s Section 504 plan or IHP/AAP. Staff should be aware of and implement the emergency plan, if a reaction is suspected.
2. In collaboration with the teacher, nurse and parents/guardians of the allergic student, a classroom plan regarding the management of food in the classroom will be developed.
3. The classroom teacher will notify parents by written communication of any schoolrelated activity that requires the use of food in advance of the project or activity (i.e. classroom parties, classroom rewards).
4. Encourage proper hand washing before and after eating.
5. All staff should be responsible for personal food consumption within the school setting with consideration to students with life-threatening food allergies.
1. If you are aware of a student’s exposure to a possible food allergen or notice ANY signs of an allergic reaction, contact the nurse immediately.
2. In the event a student has an allergic reaction at school and the nurse is unavailable, call 911 and administer emergency medication (i.e. Epi-Pen) as indicated by the student’s Section 504 plan or IHP.
3. When in doubt, it is better to give the emergency medication than to take the chance of the situation becoming life threatening.
4. The school principal and parent/guardian should be notified as soon as feasible.

INDIVIDUAL HEALTHCARE PLAN
SCHOOL NURSE CARE PLAN
STUDENT:
GRAEDE/TEACHER:
PARENTS:
DOB:
HOME PHONE:
EMERGENCY #:
PHYSICIAN:
DATES OF PARENT CONTACT:
HOSPITAL PREFERENCE:
MEDICAL DIAGNOSIS/CONDITION: SEVERE ALLERGIC REACTION
DATE:
REVIEW DATES:
SIGNATURES/INITIALS:
MEDICATIONS/EQUIPMENT: Severe Allergy Plan attached Carries EPI-PEN
Possible triggers: (check all that apply)
Tree nuts
Usual signs and symptoms: (Check all that apply)
Wheezing Shock
Peanuts
Eggs
Medication
Insect bites or stings Type: ______
Other: _______________________
Difficulty breathing/talking Loss of consciousness
Chest pain or tightness Other __________________________
Itching
Hives
Swelling of face, throat, tongue or eyes
NURSING DIAGNOSIS
Potential life-threatening condition due to allergic reaction.
GOALS
Decrease number and severity of allergic reactions.
Quickly recognize signs of severe allergic reaction.
Stabilize after exposure.
INTERVENTIONS
1. Minimize exposure to triggers.
Inform staff members of potential
triggers and strive to eliminate them.
2. Assess reaction to exposure.
Notify parent.
Monitor A – airway B – breathing
C – circulation.
CALL 911 IF SEVERE REACTION
AND/OR EPI-PEN IS USED.
3. Assess O2 sat.
4. Administer prescribed medication after
exposure:
Name: Dose:
May repeat in 5 minutes.
Use Epi-pen per standing order, if needed.
Take student’s Epi-pen on filed trip.
Train at least 1 staff member going on field trip using trainer pen.
5. Other:
EVALUATION
DATES
Yearly, after hospitalization, and as needed.
Date Initials

Name of Student:
Birth Date:
Parent Name:
Telephone:
Medical Statement for Student Requiring Special Meals
School District:
School Attended:
Telephone:
For Physician’s Use
Identify and describe disability, or medical condition, including allergies that require the student to have a special diet. Describe the major life activities affected by the student’s disability (see back of form).
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Diet Prescription (check all that apply):
Diabetic (include calorie level or attach meal plan) Modified Texture and/or Liquids
Reduced Calorie Food Allergy (describe): ________________________________________
Increased Calorie Other (describe): ______________________________________________
Food Omitted and Substitutions:
Use space to list specific food(s) to be omitted and food(s) that may be substituted. You may attach an additional sheet if necessary.
OMITTED FOODS SUBSTITUTIONS
_____________________________________ _____________________________________
_____________________________________ _____________________________________
_____________________________________ _____________________________________
Indicate Texture:
Regular Chopped Ground Pureed
Indicate thickness of liquids:
Regular Nectar Honey Pudding
Special Feeding Equipment : __________________________________________________________
Additional Comments: ___________________________________________________________________
I certify that above named student needs special school meals as described abo ve, due to the student’s disability or chronic medical condition.
__________________________________ ____________________________ ______________________
Physician’s Signature Telephone Number Date
__________________________________ ____________________________ ______________________
Signature of Preparer or Other Contact Telephone Number Date
I hereby give my permission for the school staff to follow the above stated nutrition plan.
______________________________________________________ _______________________________
Parent/Guardian Date

United States Department of Agriculture
Food and Nutrition Service Instruction 783-2
7 CFR PART15b
“Handicapped person” means any person who has a physical or mental impairment which substantially limits one or more major life activities, has record of such an impairment, or is regarded as having such an impairment.
“Physical or mental impairment” means (1) any physiological disorder or condition, cosmetic disfiguration, or anatomical loss affecting one or more of the following body systems:
Neurological, musculoskeletal, special sense organs, respiratory, including speech organs, cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic skin, and endocrine or (2) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. The term “physical or mental impairment” includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairments; cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental retardation, emotional illness, drug addiction, and alcoholism.
“Major life activities” means functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

FILE: JHCF-AF1
Critical
STUDENT ALLERGY PREVENTION AND RESPONSE
(Allergy Action Plan – Physician Statement)
Allergy to: ______________________________________________________________________________
Student: ___________________________ DOB: ____________ GR: __________ Teacher: _____________
Does student have history of asthma? Yes No
Signs of an allergic reaction specific to your child: _______________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
For Minor Reaction (Check all that apply.)
1. If symptoms are: ______________________________________________________________, give
(medication, dose, route) ___________________________________________________________.
2. Call emergency contacts below.
3. Call physician below for further directions.
For Major Reaction (Check all that apply.)
1. If symptoms are: ______________________________________________________________, give
(medication, dose, route) _______________________________________________IMMEDIATELY.
2. Call EMS.
3. Call emergency contacts below.
4. Call physician below for further directions.
DO NOT HESITATE TO CALL EMS
Additio nal information that you want the school to consider pertaining to your child’s allergies:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Physician’s Signature: ________________________ Parent Signature: _____________________________
Date: _______________ Phone: _______________ Date: _______________ Phone: _________________
EMERGENCY CONTACTS
1. _____________________________________________ 2. _____________________________________________
Relation: _______________________________________
Phone: ________________________________________
Phone: ________________________________________
Relation: _______________________________________
Phone: ________________________________________
Phone: ________________________________________
For Office Use Only: JHCF-AF1.WSR (11/10) Page 1

Page 2
FILE: JHCF-AF1
Critical
TRAINED STAFF MEMBERS TO ADMINISTER PERMEASURED EPINEPHRINE
(If any, in addition to any building school nurse)
1. ___________________________________________
Room: _______________________________________
2. ___________________________________________
Room: _______________________________________
      
Note: The reader is encouraged to review policies and/or procedures for related information in
this administrative area.
Implemented: 02/23/2011
Revised: 04/15/2011
Windsor C-1 School District, Imperial, Missouri
For Office Use Only: JHCF-AF1.WSR (11/10)

FILE: JHCF-AF4
Critical
STUDENT ALLERGY PREVENTION AND RESPONSE
(Epinephrine Medication Self-Administration)
Student Name: ________________________________________ Grade: _______ School Year: ________________
The Missouri Safe Schools Act of 1996 provides for students to carry self-administer lifesaving medications when the following criteria are met:
1. A licensed physician prescribed or ordered the medication for use by the child and instructed such child in the correct responsible use of the medication.
2. The child has demonstrated to the child’s licensed physician or the licensed physician’s designee, and the school nurse, if available, the skill level necessary to use the medication and any device necessary to administer such medication prescribed or ordered.
3. The child’s physician has approved and signed a written treatment plan for managing asthma or anaphylaxis episodes of the child and for medication for use by the child. Such plan shall include a statement that the child is capable of self-administering the medication under the treatment plan.
4.
The child’s parent or guardian has completed and submitted to the school any written documentation required by the school, including the treatment plan required in (3) above and the liability statement required in (5) below.
5. The child’s parent or guardian has signed a statement acknowledging that the school district and its employees or agents shall incur no liability as a result of any injury arising from the self-administration of medication by the child or the administration of such medication by school staff. Such statement shall not be construed to release the school district and its employees or agents from liability for negligence. (Missouri Revised Statute: Chapter 176; Pupils and Special Services; Section 167.627;08-28-2006).
Medication Name : __________________________ Dose: __________________ Time or Interval: _________________________________
Route/Inhalation Device: ______________________ Instructions: ______________________________________________________________
Medication Name : __________________________ Dose: __________________ Time or Interval: _________________________________
Route/Inhalation Device: ______________________ Instructions: ______________________________________________________________
Allergies (List known allergies to medications, foods or air-borne substances.)
_____________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
I, the parent or legal guardian of the student listed above, give permission for this child to carry and self-administer the above-listed medications. I have instructed my child to notify the school staff anytime this device is used. I understand that, absent any negligence, the school shall incur no liability as a result of any injury arising from the self-administration of medication by my child.
Signature of Parent or Legal Guardian : ___________________________________________ Date: __________________________
Parent/Guardian:
Name: _________________________________________ Home Phone: _________________________________________________
Address: _______________________________________ Work and Cell Phones: _________________________________________
Name: _________________________________________ Home Phone: _________________________________________________
Address: _______________________________________ Work and Cell Phones: _________________________________________
Emergency Contact:
Name: ______________________________________ ___ Phone #’s: ___________________________________________________
I, a licensed physician or nurse practitioner, certify that this child has a medical history of severe allergic reactions, has been trained in the use of the listed medication, and is judged to be capable of carrying and self-administering the listed medication(s). The child should notify school staff anytime the medication/injector is used. The child understands the hazards of sharing medications with others and has agreed to refrain from this practice.
Signature of Healthcare Provider : ____________________________________________________________ Date: _____________________
Name of Healthcare Provider: _________________________________ Phone: _______________________ Fax: ________________________
Address: __________________________________________________ City: _________________________ Zip: ________________________
      
For Office Use Only: JHCF-AF4.WSR (11/10) Page 1

Page 2
FILE: JHCF-AF4
Critical
Note: The reader is encouraged to review policies and/or procedures for related information in
this administrative area.
Implemented: 02/23/2011
Revised: 04/15/2011
Windsor C-1 School District, Imperial, Missouri
For Office Use Only: JHCF-AF4.WSR (11/10)

FILE: EFEA
BASIC
DISTRIBUTION OF NON-COMMERCIAL FOODS
(Shared Foods in the School Environment)
In the interest of providing a safe and healthy environment, the Windsor C-1 School District prohibits the consumption of shared foods during the school day. Some medical conditions and allergic reactions to food ingredients pose a serious risk to student safety. This risk is higher when food ingredients are unknown or when appropriate food preparation conditions cannot be controlled. Therefore, only prepackaged foods with nutritional labeling may be brought to school for student consumption. Home-prepared foods are not permitted or sold to students during the school day. This policy does not pertain to students’ individual lunches and /or snacks brought from home for personal consumption.

Please sign on the line below acknowledging that you have read and understand the
Windsor C1 School District’s Student Allergy Prevention and Response Policy. If you have any questions, please contact the principal or school nurse.
___________________________________________ _____________________
Parent Signature Date
___________________________________________
Parent Printed Name