Report for the Emergency Administration of Epinephrine
Name of County:
*
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
DeKalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
LaPorte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
Scott
Shelby
Spencer
St. Joseph
Starke
Steuben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
Date of Epinephrine Administration:
*
-
Month
-
Day
Year
Date Picker Icon
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
History of Allergy
*
Yes
No
Unknown
Specific Allergen that Triggered Anaphylaxis Event
*
Peanuts
Tree Nuts
Shellfish
Milk
Insect
Exercise
Medication
Latex
Unknown
Other
Allergen that Triggered Anaphylaxis Event Was
*
Ingested
Touched
Inhaled
Other
Location Where Epinephrine Administered
*
Health Clinic
Classroom
Cafeteria
Gymnasium
Playground
Bus
Other
Epinephrine Administered By
*
RN
LPN
Health Aide
Non-licensed School Personnel
Self-administered by Person
Other
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
Other
Was a Second Dose of Epinephrine Required
*
Yes
No
Unknown
Was the Person Transported via EMS to a Local Medical Facility
*
Yes
No:
If EMS was not notified, please select the reason: (check all that apply)
*
Assessed, treated, symptoms resolved, and returned to class
Home with parent
Taken to healthcare provider by parent
Transported to Emergency Medical Services (EMS) by parent
Parent refused EMS transport
Other
Explain Why, if EMS was not Notified:
Title of Person Completing Form
*
RN
LPN
Health Aide
Non-licensed School Personnel
Other
Submit
Created for Jolene Bracale on 03/27/2017
Should be Empty: