Report for the Emergency Administration of Epinephrine
School Corporation Name:
*
School Corporation Number:
*
Name of School:
*
School Number:
*
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
Time of Epinephrine Administration:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Route of Administration
*
Auto-injectable
Ampule/Bottle and Syringe
Type of Person Emergency Medication Given to
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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
Submit
Created for Jolene Bracale on 03/27/2017
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