(microsoft word - authorization for management of an allergic reaction 3-05.05)

This order is valid only for the current school year_____________________
Emergency injections are usually administered by nonhealth professionals such as, a PSD employee. These persons are trained by a school registered
nurse to give the injection. 911 will be called while the student, health services staff or school staff administers the EPIPEN.

•Prescription medication must be in a container labeled by the pharmacist or health care provider.
•Over the counter medication must be in the original unopened container with the label intact.
•The provider will be called if a question arises about the student and their medication.
•Thoroughly review reverse side of form before completion.
Type of Medication/Dosage/Route of Administration: Check appropriate box (es)
 Benadryl Elixir 12.5 mg P.O.*   Benadryl Elixir 25 mg P.O.   Benadryl Elixir ____ mg P.O. 
 EPIPEN 0.15 mg IM**   EPIPEN 0.3 mg IM *P.O. – by mouth **IM Intramuscularly
Medication is to be Administered: Check appropriate box (es)
 Immediately after insect sting (bee, wasp, hornet, yellow jacket) 
 Immediately after the ingestion of (specify):____________________________________________________________
 Immediately after contact with (specify): ______________________________________________________________ 
 Unknown etiology: _______________________________________________________________________________
If Benadryl and EPIPEN Are Ordered: Check appropriate box
 Give Benadryl and EPIPEN at the same time. 
 Give Benadryl, and then wait ____ minutes, if you see (specify specific signs and symptoms i.e. audible wheezing, heart
rate above ___, tongue swelling, etc.) ___________________________________________________________________
then give EPIPEN.
Repeat EPIPEN dose in 15 minutes if EMS has not arrived**  Yes  No
**For a repeat dose, box must be checked above and parent must provide second EPIPEN for school.

Possible Medication Side Effects:
EPIPEN: palpitations, rapid heart rate, sweating, nausea and vomiting
Benadryl: drowsiness, sedation, sleepiness, dizziness, restlessness, hypotension, palpitations
Comments: _________________________________________________________________________________________
Health Care Provider’s Name/Title: (Type or Print) Use for Health Care Provider’s Address Stamp PARENT/GUARDIAN AUTHORIZATION
I request designated personnel to administer the medication as prescribed by the health care provider above. I certify that I have legal authority to consent to the administration of medication at school. Parent/Guardian Signature: SELFCARRY/SELFADMINISTRATION AUTHORIZATION/APPROVAL
Self-carry and/or self-administration of prescribed medication must be authorized by the provider and approved by the school registered nurse. Health Care Provider’s authorization for: Self-Carry  Yes   No Self-Administration:  Yes   No School registered nurse approval for: Self-Carry:  Yes   No Self-Administration:  Yes   No Order reviewed and signed by school registered nurse: IMPORTANT INFORMATION FOR PARENTS/GUARDIANS AND PHYSICIANS
An acute allergic reaction can be a life-threatening situation. Completion of this form in its entirety is vital so that the EPIPEN can be administered and emergency care implemented. If the student experiences an acute allergic reaction, PSD personnel will dial 911 while the student/PSD employee/or PSD registered nurse administers the EPIPEN. Parent/guardian will be notified. An EPIPEN sent to school, must be labeled by a registered pharmacist with the name of the medication, the dose, the name of the health care provider, the name of the student, and directions for administration. The parent/guardian should note the expiration date and provide a new EPIPEN prior to expiration. The PSD employee/or PSD registered nurse must review and approve these forms in the school prior to administration. The parent/guardian, health care provider and school RN must indicate on the reverse side of this form whether the pupil is capable of self-administering the EPIPEN, if needed.

Source: http://peotoneschools.org/District/AllergyAuthorizationForm.pdf


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