Medically Diagnosed
Sensitivity / Allergic Reaction - Insect
Anson Independent School District
Health Services Department
Parent/Guardian(s)For students with medically diagnosed Anaphylaxis an effort to meet student needs and still maintain a safe environment
with regard to medications in the school setting, the following procedures have been developed and incorporated into
school health services program and must be renewed annually.
 Sensitivity – Insect Allergic Reaction Action Plan
 Parent/Physician Authorization for Self-Administration of Allergic Reaction Medication by a
Student forms (attached) must be completed as follows:
1. Completed and signed by student’s physician
2. Parent read and signature
3. Return to nurse’s office
 Each student that has a Sensitivity - Insect Action Plan must also have an Emergency
Contact Information and Consent (attached) on file in the nurse’s office.
 This information is to be provided by the parent/guardian, including the
parent/guardian(s) signature.
 Please return all completed documents to the nurse’s office.
 All medications and supplies may also be delivered once documents are on file.
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Medications will need to be in original container with prescription label attached.
Medications, and supplies need to be placed in storage (Ziplock® type) bag with
student’s name placed on outside.
All medications and supplies will need to be picked up on or before the final day of
class.
All unclaimed medications will be discarded at the end of the school year.
There will be NO medications kept in the clinic through the summer months.
Should you have any questions, I can be reached Monday-Friday 8am-3pm at 823-4475. I
appreciate your help in providing the necessary information needed to provide the best possible
care to your child.
Thank you,
Michelle Huffaker, RN
Anson ISD Health Services Department
Allergic Reaction/Sensitivity - Insect
Anson Independent School District
Health Services Department
Upon receipt of the health history information for your child, it was noted that your child had insect
sensitivity – allergies reaction. Because allergies of this type can be serious, please provide a description of
the reaction your child experiences in the space provided below.
 If you wish the school nurse and/or other Anson ISD personnel to administer medication, please sign
and return this form to my office located in the Elementary building.
 If you do not wish for medication/treatment to be administered to your child at school, please sign
and return the waiver of treatment portion to my office.
If your child has severe (breathing difficulties) allergic reactions, I urge you to discuss with your doctor the
possible need of keeping an Epi-pen (medication to be used only in the event of a life-threatening allergic
response) at school.
The nurse's office does NOT stock a single dose of epinephrine.
Insect Sensitivity
Insect Type: ____________________ Type of Reaction: □ Breathing Difficulty □ Rash
□ Hives
Insect Type: ____________________ Type of Reaction: □ Breathing Difficulty □ Rash
□ Hives
Insect Type: ____________________ Type of Reaction: □ Breathing Difficulty □ Rash
□ Hives
Insect Type: ____________________ Type of Reaction: □ Breathing Difficulty □ Rash
□ Hives
Insect Type: ____________________ Type of Reaction: □ Breathing Difficulty □ Rash
□ Hives
Insect Type: ____________________ Type of Reaction: □ Breathing Difficulty □ Rash
□ Hives
_______________________________________________
Parent/Guardian Signature
**********************************Waiver
_____________________________
Date
of Treatment************************************************
My child, _____________________________ has a severe allergic reaction to ___________________________. I have been
informed by school personnel of the required documentation needed to properly treat ___________________________ while at
school and/or school related events. I understand that it is my responsibility to provide all needed information. However, I decline
to participate in the requirements. Therefore, I do hereby agree to indemnify and save harmless the school and any school
representative from any liability arising in the event that my child, ___________________________have an anaphylaxis reaction.
_________________________________________________
Parent Signature
AISD Form X A, 7/09
____________________________
Date
Allergic Reaction/Sensitivity – Insect
Emergency Action Plan
Anson Independent School District
Health Services Department
Insect Sensitivity to:
Insect: _______________________
Insect: _______________________
Insect: _______________________
Type of Reaction: □ Breathing Difficulty
Type of Reaction: □ Breathing Difficulty
Type of Reaction: □ Breathing Difficulty
□ Rash
□ Rash
□ Rash
□ Hives
□ Hives
□ Hives
Has Student been diagnosed with Asthma? □ Yes □ No Medication given at school: ______________
Symptoms
Emergency Treatment to be completed by Physician
Mild Symptoms (Local reaction)
* Mild skin reactions
Hives/Swelling only
in the areas of
allergen contact.
Students with an Epi-pen or history of anaphylaxis must go home
With parental supervision for the remainder of the school day.
SYMPTOMS CAN BECOME MORE SERIOUS VERY QUICKLY
OR OVER THE NEXT SEVERAL HOURS.
»IF STUDENT HAS MILD SYMPTOMS OR INGESTED IS
SUSPECTED:
CALL 911
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Note time _____________ and stay with student
Watch closely for serious symptoms
Give _______________________ as ordered by
physician
Call parent or emergency contact
Stay with student until parent or EMS arrives
Call school nurse
DO NOT HESITATE TO CALL 911 OR TO GIVE EMERGENCY MEDICATION(S)
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SERIOUS SYMPTOMS (Systemic Reaction):
Skin
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Mouth
Throat
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Gut
Lungs
Heart
widespread hives and flushing, widespread
swelling
swelling of the tongue
itching, or a sense of tightness of the throat,
Hoarseness, hacking cough
vomiting, nausea, cramps, diarrhea
repetitive coughing, wheezing, trouble breathing
rapid heart rate, lightheadness, dizziness, loss of
consciousness
IF STUDENT HAS ANY SERIOUS SYMPTOMS:
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Note time _____________ and stay with student
Give ___________________ as ordered by physician
Administer Epi-pen. Follow directions on injection
Device as trained. Note time given ______________
Call 911: ask for Advance Life Support for an
Allergic reaction
Call parent or emergency contacts
Call school nurse
This Emergency Action Plan must be signed by both parent/guardian and physician
My signature below shows I reviewed and agree with this plan.
___________________________________ ______________
Parent Signature
Date
__________________________________ ____________
Physician Signature
Date
_______________________________________________
Physician’s Printed Name
Allergic Reaction/Sensitivity – Insect
Emergency Contact Information and Consent
Anson Independent School District
Health Services Department
Student Name: ____________________________________ Teacher _____________
Student Food Allergies: _________________________________________________
_________________________________________________
_________________________________________________
Student Medication Allergies: ____________________________________________
____________________________________________
____________________________________________
Grade: __________
Male: ___ Female: ___ Date of Birth: ___________________
Address: ____________________________
____________________________
____________________________
Home Phone: __________________
Cell Phone: ___________________
Emergency No.: ________________
Father’s Name: _____________________________ Work Phone: ______________ Cell Phone _______________
Mother’s Name: ____________________________ Work Phone: _______________ Cell Phone _______________
In case parents can not be reached at time of emergency, please call:
Name: _________________________________ Phone: _______________________
Relationship to student: _________________ Phone: ________________________
Name: _________________________________ Phone: _______________________
Relationship to student: _________________ Phone: ________________________
Unfortunately, there is always the possibility of an accident occurring to a student at school or while participating in
an after-school activity. In case an accident should occur, the school and/or the UIL does not assume
responsibility. Nevertheless, if an accident should occur, a discretionary judgment will be made by a school
representative in regard to the student’s need for immediate care and treatment. Therefore, I do herby request,
authorize, and consent to such care and treatment as may be given to the said student by and physician, trainer,
nurse or school representative. As well, I do hereby agree to indemnify and save harmless the school and any
school representative from any claim by any person whomsoever on account of such care and treatment of the said
student.
Between this date and the end of the school year, illness or injury could occur that may limit the student’s
participation, I agree to notify the school authorities of such illness or injury.
________________________________
Signature of Parent/Guardian
_________________________
Date
______________________________
_______________________
Signature of Parent/Guardian
Date
Allergic Reaction/Sensitivity – Insect
Parent/Physician Authorization for Self-Administration of Allergy Medication
By a Student
Anson Independent School District
Health Services Department
Parent Authorization
I have reviewed the attached guidelines and procedures for Self-Administration of Prescription Anaphylaxis
Medication by Students; discussed them with my child; and request that my child be able to possess and selfadminister his/her prescription anaphylaxis medication while on school property or at a school-related event or
activity. I understand that the anaphylaxis medication must be prescribed for my child as indicated on the
prescription label, which must be affixed to the medication container (inhaler canister or packaging box). I release
the school district and employees of any liability arising from self-administration.
_____________________________________________________
Parent/Guardian Signature
___________________________
Date
Physician Authorization
The medical history and my examination of _______________________________________________,
Students Name
indicates that he/she does have anaphylaxis. The student has been educated and is knowledgeable about his/her
anaphylaxis and can properly self-administer the prescribed medication and determine its effectiveness.
Name of Medication: __________________________________________________________________
Purpose of Medication: _________________________________________________________________
Prescribed Dosage: ____________________________________________________________________
Times at which or circumstances under which the medicine may be administered:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Period of time for which the medicine has been prescribed:
□ Long Term (chronic condition)
□ Short Term and should be discontinued by ________________________
Date
________________________________________
Physician’s Printed Name
________________________________________
Physician’s Signature
Office Telephone Number: ______________________________________
Diagnosed Medical Condition
Insect Sensitivity – Allergic Reaction
Waiver of Treatment
Anson Independent School District
My child, _________________________________ has been medically diagnosed and/or treated
for Insect Sensitivity – Allergic Reaction and I have been informed by Anson ISD, school personnel of
the required documentation needed to properly treat him / her while at school and/or school related
events. I understand that it is my responsibility to provide to the school all needed information and
medication. However, I decline to participate in the requirements. Therefore, I do herby agree
to indemnify and save harmless the Anson ISD and any of its representatives from any liability
arising in the event that my child, listed above, have an Insect Sensitivity and/or Allergy-like related
episode.
________________________________________
Parent Signature
__________________________
Date
________________________________________
Parent Printed Name
___________________________
Phone Number