Report for the Emergency Administration of Epinephrine

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

MonthDayYear
Route of Administration*

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

StudentStaffVisitor
Approximate Age of Person Receiving Medication:*
Gender of Person Receiving Medication*

MaleFemale
History of Allergy*

YesNoUnknown
Specific Allergen that Triggered Anaphylaxis Event*

PeanutsTree NutsShellfishMilkInsectExerciseMedicationLatexUnknownOther
Allergen that Triggered Anaphylaxis Event Was*

IngestedTouchedInhaledOther
Location Where Epinephrine Administered*

Health ClinicClassroomCafeteriaGymnasiumPlaygroundBusOther
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
Location Epinephrine Was Stored*

Health ClinicCarried by the PersonCabinet or Location Outside the Health ClinicOther
Was a Second Dose of Epinephrine Required*

YesNoUnknown
Was the Person Transported via EMS to a Local Medical Facility*

YesNo:
If EMS was not notified, please select the reason: (check all that apply)*

Assessed, treated, symptoms resolved, and returned to classHome with parentTaken to healthcare provider by parentTransported to Emergency Medical Services (EMS) by parentParent refused EMS transportOther
Explain Why, if EMS was not Notified:
Title of Person Completing Form*

RNLPNHealth AideNon-licensed School PersonnelOther
Created for Jolene Bracale on 03/27/2017
Should be Empty: