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HENRY P. BECTON REGIONAL HIGH SCHOOL
Phone: (201)-935-3007 Fax: (201)-935-5639
Epinephrine Auto-Injectior(Epipen)/ALLERGY MEDICATION
MUST BE RENEWED EACH SCHOOL YEAR School Year: ____________
Student Name:_____________________________ DOB:___________Grade:____
TO BE COMPLETED BY A PHYSICIAN: PLEASE COMPLETE BOTH SIDES
****NOTE TO PHYSICIAN/PARENT:****
State law only permits a student to self-administer an epinephrine auto-injector (Epipen), or
Benadryl simultaneously with an Epipen. An order of Benadryl first, then Epipen upon
further symptoms requires a medical assessment, and therefore, that order is not permitted
during school or school-sponsored activities unless it is performed by a nurse, physician, or a
parent who is present. A delegate or the student may not observe and then administer
Benadryl.

The above student is allergic to:______________________________________________
To control reactions the following medications are prescribed:
__________Epipen Sr.
__________Epipen Jr.
Other:__________________________________________________________________
Name of Medication and Specific Dosage
(may not be self-administered unless Benadryl prescribed simultaneously with Epipen)
The epinephrine auto-injector is to be given:

___________Immediately (do not wait for symptoms)
___________After the following symptoms occur (please check those that pertain):
_____Apprehension _____Itching/Skin Burning
_____Sneezing/Coughing _____Wheezing/Shortness of Breath
_____Hives _____Cyanosis
_____Difficulty Breathing _____Loss of Consciousness/Drowsiness
_____Loss of Color
_____Flushing Other:_____________________________
If Benadryl is prescribed above with an Epipen order, it is to be given:
_________Simultaneously with Epipen (No observation for symptoms to occur before Epipen)
_________Before an Epipen, as the first medication given (please circle one) before // after
any of above symptoms occur. After giving Benadryl, if symptoms do not improve
within_______ minutes, administer the Epipen. (this order is permitted only to school nurse,
physician, or parent)
*********PLEASE COMPLETE BOTH SIDES*********
Epinephrine Auto-Injector (Epipen) will be kept:

___________In the possession of student to SELF-ADMINISTER (student is capable of and
has been instructed in the proper administration of the Epipen)
___________Stored in a secure unlocked location to be administered by nurse, or an assigned
delegate, if permitted)

***The State recommends that a back-up/spare epinephrine auto-injector be
supplied by the student’s parent/guardian. Licensed Provider: Please include
this in your orders ***


Benadryl may ONLY be self-administered when the physician’s order states that the
prescribed Benadryl dose is to be given SIMULTANEOUSLY with an Epipen, without
observation for symptoms. Student is permitted in school to carry only the prescribed
dose of Benadryl with an Epipen, when ordered to be given simultaneously with the
Benadryl. A student MAY NOT administer Benadryl, observe himself, then self-
administer Benadryl if needed. By law, only a nurse may follow such an order at a school-
sponsored activity.

SCHOOL-SPONSORED EVENTS and/or VARSITY ATHLETIC PARTICIPATION
(Please check):

For Health Providers who have designated the school nurse to medicate during school
hours:
Orders for field trips, varsity athletics, or intramurals may differ from regular school hour
orders. If a school nurse is ordered to give the medication in school, please have the provider
check below whether the student may self-administer only the orders in accordance to bold
lettering above during school-sponsored events and athletic sports.
Student __________MAY _______________ MAY NOT self-administer the above
medication(s) on school-sponsored events or during varsity athletics.
State law states that a school nurse shall assign a delegate, who volunteers and is properly
trained, to administer a student’s auto-injector epinephrine if student is incapable,
should the nurse or parent be unavailable. Physicians, please discuss this with your
patient.

____________________________________ _____________________________
Physician’s Name Physician’s Signature
______________________ Physician’s Stamp:
Date

Source: http://capetrinitycatholic.com/bhs/Community%20Information/Health%20Updates/Epipen.pdf