Report for the Emergency Administration of Epinephrine

Report for the Emergency Administration of Epinephrine
School Corporation Name: *
School Corporation Number: *
Name of School: *
School Number: *
Name of County: *
Date of Epinephrine Administration: *

Month Day Year
Time of Epinephrine Administration: *

: Hour Minutes AM/PM Option
Route of Administration *

Auto-injectable Ampule/Bottle and Syringe
Type of Person Emergency Medication Given to *

Student Staff Visitor
Approximate Age of Person Receiving Medication: *
Gender of Person Receiving Medication *

Male Female
Ethnicity of Person Receiving Medication

Yes, Spanish/Hispanic or Latino No, not Spanish/Hispanic or Latino
Race of Person Receiving Medication

American Indian/Alaskan Native African American Asian Native Hawaiian/Other Pacific Islander White
History of Allergy *

Yes No Unknown
If Yes, was an Allergy Action Plan and/or Medical Treatment Orders Available at the School *

Yes No
Did this Person have a History of Previous Epinephrine Administration? *

Yes No Unknown
Vital Sign - BP:
Vital Sign - Pulse:
Vital Sign - Respirations:
Specific Allergen that Triggered Anaphylaxis Event *

Peanuts Tree Nuts Shellfish Milk Insect Exercise Medication Latex Unknown
Allergen that Triggered Anaphylaxis Event Was *

Ingested Touched Inhaled
Did Reaction Begin Prior to School?

Yes No Unknown
Location Where Symptoms Developed *

Classroom Cafeteria Health Clinic Gymnasium Playground Bus
Please Describe How Exposure Occurred: *
Respiratory Symptoms (Check All that Apply)

Cough; Difficulty Breathing; Hoarse Voice; Nasal Congestion; Swollen Tongue or Throat; Shortness of Breath; Stridor; Tightness of Chest or Throat; Wheezing;
GI Symptoms (Check All that Apply)

Abdominal Discomfort; Diarrhea; Difficulty Swallowing; Nausea; Vomiting;
Skin Symptoms (Check All that Apply)

Angioedema; Flushing; General Rash; Hives; Lip Swelling; Localized Rash; Pale;
Cardiac/Vascular Symptoms (Check All that Apply)

Chest Discomfort; Cyanosis; Dizziness; Faint/Weak Pulse; Headache; Hypotension; Tachycardia;
Other Symptoms (Check All that Apply)

Diaphoresis; Irritability; Loss of Consciousness; Metallic Taste; Red Eyes; Sneezing;
Location Where Epinephrine Administered *

Health Clinic Classroom Cafeteria Gymnasium Playground Bus
Epinephrine Administered By *

RN LPN Health Aide Non-licensed School Personnel Self-administered by Person
Epinephrine Was

Student’s Own Epinephrine Provided to the School by the Parent Staff or Visitor’s Own Epinephrine Stock Epinephrine Provided by the School
Location Epinephrine Was Stored *

Health Clinic Carried by the Person Cabinet or Location Outside the Health Clinic
Time Elapsed Between Communication of Symptoms and Administration of Medication Was *

Less than 5 Minutes 5-10 Minutes 10-20 Minutes 20-30 Minutes 30-60 Minutes More than 60 Minutes
Was an Individual Health Plan (IHP) in Place for this Person *

Yes No Not a Student
Was a Second Dose of Epinephrine Required

Yes No Unknown
Was the Person Transported via EMS to a Local Medical Facility *

Yes If EMS was not Notified, Please Explain Why:
Explain Why, if EMS was not Notified:
Describe the Student/Staff/Visitor Outcome (Check All that Apply) *

Released from Medical Facility Within 6 Hours; Released from Medical Facility Within 24 Hours; Prescribed Epinephrine by Medical Facility Provider; Returned to School Next Day; Follow Up Appointment Scheduled with Primary Care Provider or Specialist; EMS was Called, but Parent/Guardian/Adult Refused Transport; Unknown;
Other Comments:
Name of Person Completing Form: *

First Name Last Name
Title of Person Completing Form *

RN LPN Health Aide Non-licensed School Personnel
Email of Person Completing Form: *

Confirmation Email
Created for Jolene Bracale on 03/27/2017
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