Report for the Emergency Administration of Epinephrine

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

MonthDayYear
Type of Person Emergency Medication Given to*

StudentStaffVisitor
Epinephrine Administered By*

RNLPNHealth AideNon-licensed School PersonnelSelf-administered by PersonOther
Epinephrine Was*

Student’s Own Epinephrine Provided to the School by the ParentStaff or Visitor’s Own EpinephrineStock Epinephrine Provided by the School
Title of Person Completing Form*

RNLPNHealth AideNon-licensed School PersonnelOther
Should be Empty: