Anaphylaxis Emergency Care Plan
Individual Health Care Plan
Student:_____________________________________ Birthdate: ________ Grade: ____ Date:________
Life Threatening Allergy To:__________________________ (Asthmatic:  Yes  No)
Background Information: Anaphylaxis is a serious life-threatening reaction which occurs
when exposed to an allergy causing substance (food, bee stings, environmental).
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Medication:
Epinephrine auto-injector 0.3mg
Epinephrine auto-injector 0.15mg
_______________________________________________________________________________
Symptoms of anaphylaxis:
(Never send a student with suspected allergic response anywhere alone!)
Mouth - Itching, tingling, or swelling of the lips, tongue or mouth
Skin - Hives, itchy rash, and/or swelling about the face or extremities
Throat - Sense of tightness in the throat, hoarseness and hacking cough
Gut - Nausea, stomach ache/abdominal cramps, vomiting and/or diarrhea
Lung - Shortness of breath, repetitive coughing, and/or wheezing
Heart - "Thready" pulse, "passing out," fainting, blueness, and pale
General -Panic, sudden fatigue, chills, fear of impending doom
Other - _______________________________________________________
Emergency Action Plan If you suspect a life-threatening allergic reaction or known
ingestion/contact/exposure to a life-threatening allergen:
1.
Administer epinephrine auto-injector and call 911 (DO NOT HESITATE
to administer epinephrine)
2.
911 must be called if epinephrine auto-injector is administered.
3.
Call school nurse or office staff. Call parent/guardian.
4.
Stay with student, administer CPR if needed.
5.
Students who self carry/administer must notify an adult staff member if
they use their epinephrine auto-injector. 911 must be called.
6.
Other:______________________________________________________
___________________________________________________________
___________________________________________________________
Epinephrine auto-injector is located in:
_____________________________________________________
Emergency contact information: Parent/Guardian
#1 Call:_______________________
#2 Call:_______________________
Home#:_______________________
Home#:_______________________
Cell#:_________________________
Cell#:_________________________
Work#:_______________________
Work#:_______________________
*Continued on back*
Individual Considerations for Anaphylaxis Care Plan
Bus - Transportation must be alerted to student's allergy.
* Does this student ride the bus?

 Yes
 No Bus # _______
* This student carries epinephrine auto-injector on the bus
 Yes
 No
* Epinephrine auto-injector can be found in
 Backpack
 Waistpack  On Person  Other (specify)
* Student will sit in front of bus
 Yes
 No
* Other (specify) _________________________________________________________
Field Trip Procedures – Epinephrine auto-injector must accompany student during any off campus activities.
* Staff members on trip must be trained regarding epinephrine auto-injector use.
* Staff members on trip must be trained regarding this health care plan. (Health care plan must be taken on field trip.)
* The student must remain with the trained staff member during the entire field trip.
* Other (specify) _________________________________________________________
FOR STUDENTS WITH FOOD ALLERGIES:
Classroom (Food Allergy) This student is allowed to eat only the following foods:
 Student may eat snacks provided in the classroom.
 Those in manufacturer's packaging with ingredients listed and determined allergen-free by the parent.
 Those approved by parent.
 Middle school or high school student will be making his/her own decision.
 Alternative snacks will be provided by parent/guardian to be kept in the classroom.
 Parent/guardian should be advised of any planned parties as early as possible.
 Classroom projects should be reviewed by the teaching staff to avoid specified allergens. Questions, contact parent.
* Student should have someone accompany him/her in the hallways.
 Yes  No
* Other (specify) _________________________________________________________
Cafeteria (Food Allergy)
 NO Restrictions
 Student will bring lunch from home.
 Student will sit at specified allergy table.
 Student will sit at the classroom table cleansed according to procedure guidelines prior to student's arrival and
following student's departure.
 Student will sit at the classroom table at a specified location.
* Cafeteria staff must be alerted to student's allergy.
* Care plan posted in cafeteria in a private place
 Yes
 No
* Other (specify) _________________________________________________________
Recess/PE:
 Student is able to participate in all activities.
* Other (specify)__________________________________________________________
*Parent/guardian is responsible for notifying after school activities program staff/adult/coach of all aspects of students allergy needs.
*The best way to prevent accidental ingestion of known allergen is to provide meals from home. If eating meals at school, Diet Prescription
Form submitted to Food Services for appropriate restrictions.
***I understand the above information may be shared with school district staff as needed to protect the health and safety of this student and to
plan for a safe environment conducive to learning.***
Parent/Guardian Signature: _________________________________________________ Date: _____________
School Nurse Signature: ___________________________________________________ Date: ______________
_______________________________________________________________________ Date: ______________
Student demonstrates skill level necessary to self-administer medication as ordered by Licensed Health Care Provider.
School Nurse Signature:
Date:
5-17-13