HEALTH PACKET. EPI-PEN, ASTHMA and ALLERGY

Transcription

1 HEALTH PACKET EPI-PEN, ASTHMA and ALLERGY

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4 Epi-Pen and/or Inhaler Agreement Child s Name: Class: Name of Medication (s): Yes No I authorize the school nurse/director to contact my physician with any questions related to the care of my child. Yes No I authorize the school nurse or other unlicensed assistive individuals trained by the nurse, to administer the above medication(s) to my child during regular school hours and at other times when my child is participating in a school related event. Yes No I authorize my child to engage in self-administration if authorized and approved by the child s physician. The student will be able to demonstrate correct administration procedure. All medication must be stored in a secure location within the school. If self-administering, the student is responsible for carrying it at all times. No medication may be stored in a student s locker or left unattended. This is for the safety of the entire student body. I understand that The Village School,the school nurse and other school employees shall incur no liability as a result of any injury arising from the administration of this medication either administered by the nurse or the child themselves; and that I will indemnify and hold harmless The Village School, its Board of Trustees, their employees, school nurse and other school employees and the BCDHS against any claims arising from the administration of this medication to my child. Parent Print Parent Signature Date Acknowledged and Reviewed by: Updated 1/10/18

5 The Village School 100 W. Prospect Street, Waldwick, NJ Health Office Ext (Fax) Physician s Orders for Allergy Emergency Treatment Individualized Emergency Care Plan Student s Name: Birth Date: Class: Physician s Orders: (To be filled out by Physician) The above student is allergic to: Previous episode of anaphylaxis Yes No If yes, please explain: History of asthma Yes No If yes, supply Asthma Action Plan MEDICATIONS Antihistamine: Name Dose: Give antihistamine for the following symptoms: Epinephrine: EpiPen EpiPen Jr. Other Give Epinephrine for the following symptoms: Choose one administration order: Give Anthihistamine first, observe, for further symptoms and give Epinephrine PRN Give Antihistamine only Give Epinephrine only This student has been trained and is capable of self-administration of the following medication(s) Epinephrine single dose unit This student is not capable of self-administration of the medications named above. Please Note: Under NJ state law, in the absence of a school nurse, a trained delegate will give epinephrine only, any antihistamine order will be disregarded. Physician s Name: Physician s Signature: Physician s Address: Physician s Phone: Date: (Over) Page 1 of 2

6 Authorization: To be Filled out by Parent: Emergency Contact #1 Relationship: Phone # Emergency Contact #2 Relationship: Phone # Emergency Contact #3 Relationship: Phone # I authorize the school nurse/principal/administrator to contact my physician on any questions related to the care of my child s care. I also authorize the school nurse or other unlicensed assistive individuals educated by the nurse to administer the above medication to my child during regular school hours and at other times when my child is participating in a school related event. I authorize my child to engage in self-administration if appropriate. I understand that the district, school, school nurse and other school employees shall incur no liability as a result of any injury arising from the administration of this medication; and that I will indemnify and hold harmless The Board of Education/School District, Bergen County Department of Health Services and their employees, school, school nurse and other school employees against any claims arising from the administration to my child. Child s Name: Parent s Name: Signature: Date (Parent/Guardian) Administration: (To be filled out by school administration) Location of Medication and other supplies: Health Office and Classroom Treatment Protocol: 1. Follow Physician s Orders for allergy emergency treatment 2. Administer injection 3. Call 911 and notify emergency personnel of severe allergic reaction, the allergen and that an epinephrine injection has already been given or is in the process of being given. Request paramedic transport. 4. Call parent or emergency contact, school administration, physician and school nurse. 5. Record administration of medication on health record. 6. Follow up with emergency room visit. The following are authorized trained delegates(s) to administer in the absence of a school nurse Staffshare/Office/healthforms&letters/ Updated 1/10/18 Page 2 of 2

7 The Village School Health Office 100 W. Prospect Street Waldwick, NJ Ext. 234 Fax: Allergy Snack Form Please return this form to The Village School Health Office prior to the start of school if your child(ren) has a documented food allergy. This form will be in effect upon receipt for the duration of your child s enrollment at the Village School. Child s Name: Class: I have provided The Village School with information regarding my child s allergies. I want my child,, to be served ONLY the snack I have provided. I have provided The Village School with information regarding my child s allergies. My child,, may eat the community snack if the snack does not contain and/or the packaging does not indicate the allergen specified on my child s medical forms.* Parent/Guardian Name Date *All decisions regarding product content will be based on product labeling. Homemade snacks will not be served to children with food allergies as the school cannot guarantee their preparation. Form updated 6/7/17 parent/guardian

8 The Village School 100 West Prospect Street Waldwick, NJ SELF-MEDICATION RELEASE (This form is for students requiring Epi-pens) Students requiring auto-injectors (Epi-Pen) for emergency use are permitted to self-carry these medications. These medications will remain with the student at all times. Please complete this form: We request that (child s name) be permitted to carry the following on her/his person: EpiPen Auvi-Q Other She/he has been instructed in and understands the medication s purpose, frequency, and appropriate method of use. Physician s Printed Name Physician s Signature Date: As I consider my child responsible, I will not hold personnel responsible for any problems that may arise with regards to my child s self-administered medication. Parent s Printed Name Parents Signature Date: 1/10/18

9 The Village School 100 West Prospect Street Waldwick, NJ SELF-MEDICATION RELEASE (This form is for students requiring inhalers or Epi-pen) Students requiring inhalers for asthma and auto-injectors (Epi-Pen) for emergency use are permitted to selfcarry these medications. These medications will remain with the student at all times. Please complete this form: We request that (child s name) be permitted to carry the following on her/his person: inhaler Type of Inhaler: EpiPen She/he has been instructed in and understands the medication s purpose, frequency, and appropriate method of use. Physician s Printed Name Physician s Signature Date: As I consider my child responsible, I will not hold personnel responsible for any problems that may arise with regards to my child s self-administered medication. Parent s Printed Name Parents Signature Date: 1/10/18