Indian Hill Exempted Village School District Auto-injector (Epi-pen) Self-carry Plan

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1 Indian Hill Exempted Village School District Auto-injector (Epi-pen) Self-carry Plan To provide the best care for our students, two options are available for administration of an auto-injector (Epi-pen) for students with serious and/or life-threatening food allergies. Option #1 After parent and physician complete the appropriate medication authorization form, and provide the nurse/health specialist with the prescribed (auto-injector) Epi-pen, the student comes to the building clinic where the auto-injector (Epi-pen) is kept to have the medication administered under supervision. The objective of this option is to insure that an allergic reaction is taking place, that the medication will be used correctly, in the proper amount, and the time of use will be documented. This also insures that follow-up care is provided. Option #2 Qualified students that meet or exceed the requirements listed below will be allowed to carry and use an auto-injectors ( Epi-pens). The objectives of this option are immediate accessibility and facilitation of self-responsibility for medication use. A qualified student is one who has: Completed the Medication Procedure/Student Assessment Form (that allows carrying and self-medication with an auto-injector for students with life-threatening food allergies signed by parent, student, physician, and nurse/health specialist). Demonstrated correct use of the auto-injector. Agreed to never share the auto-injector with anyone. Agreed to keep the auto-injector in the agreed upon designated area. Agreed to contact an adult to inform them of the allergic reaction prior to using the auto-injector. This will insure that the building nurse/health specialist will be able to provide care and follow-up treatment. Medication Procedure That Allows Carrying And Self-Medication With An Autoinjector (Epi-pen) For Students With Serious Food Allergies Parent, Student, Physician and Nurse/Health Specialist Must Sign Student Information (to be filled out and signed by parent/guardian) Date Student s Name Grade DOB School Year Teacher s Name (if applicable) Parent/Guardian Name Home Phone Address Cell# Work# Emergency Contact Phone Physician (for food allergy) Phone Hospital Preference (for emergency) 1. What is your child s food allergy?

2 2. Has your child had a reaction to a food or was he/she diagnosed after a skin test? 3. If they have experienced a reaction in the past, what reaction did your child experience? (include any aura before physical signs) 4. Has your child been hospitalized for a food allergy reaction? 5. Has your child ever had to use epinephrine for an allergic reaction? 6. List any other medical conditions your child presently has. 7. List any medications your child presently takes. Student Action Plan (for students carrying auto-injectors (Epi-pens) The following are signs of an allergic reaction: Mouth ITCHING AND SWELLING OF LIPS, TONGUE OR MOUTH Throat ITCHING AND/OR SENSE OF TIGHTNESS IN THE THROAT, HOARSENESS AND COUGH Skin HIVES, ITCHY RASH, AND /OR SWELLING ABOUT THE FACE OF EXTREMITIES Gut - NAUSEA, ABDOMINAL CRAMPS, VOMITING, AND/OR DIARRHEA Lungs SHORTNESS OF BREATH, REPETITIVE COUGHING AND/OR WHEEZING Heart THREADY PULSE, LOSS OF CONSCIOUSNESS General LETHARGY, WEAKNESS ** A sense of foreboding, fear or apprehension often precedes an allergic reaction. Take the following action if any of the above signs appear. 1. The student will notify a supervising adult to contact the building nurse/health specialist that an allergic reaction to food is occurring. Be sure to clearly state name. 2. Have supervising adult accompany student to the designated location of the autoinjector (Epi-pen). 3. Administer the auto-injector (Epi-pen) per instructions and stay at the location until the nurse arrives. 4. Nurse will perform an emergency assessment will be called. The nurse will stay with the student until EMS arrives. 6. The nurse will notify the office staff to contact parent to arrange to meet EMS at school or hospital. 7. Auto-injector (Epi-pen) will be disposed of per universal precautions. 8. If the reaction occurs in the classroom, the teacher will reassure other students that the classmate is being cared for appropriately. 9. Nurse will document incident and contact parents for follow-up care. Field Trip Action Plan 1. The student will notify a supervising adult that an allergic reaction to food is occurring and they are carrying an auto-injector (Epi-pen) and have permission to use it. (Teachers will be carrying all student Emergency cards and have prior knowledge of students with food allergies and those who have self-carry plans).

3 2. The adult will stay with the student during the administration of the auto-injector (Epi-pen) will be called. * FYI - All buses have phones. 4. Parents will be contacted and arrangements will be made to meet EMS at the designated hospital. 5. Teacher will give auto-injector (Epi-pen) to EMS personnel for disposal. 6. Teacher will reassure other students on the field trip that their classmate is being cared for appropriately. 7. Teacher will notify the building nurse/health specialist of the incident. 8. Nurse will notify parents for follow-up. The incident is to be documented in the student s health file. During Bus Transportation. 1. The student will notify the bus driver that an allergic reaction to food is occurring and he/she has an auto-injector (Epi-pen) and has permission to use it. (Bus drivers will have prior knowledge of students with food allergies and those who have self-carry plans. 2. The bus driver will pull to the side of the road. 3. While the student is administering the auto injector, the bus driver will notify 911 and inform EMS of the location of the bus. If auto injector used, the syringe will be given to EMS for disposal. 4. Notify the transportation office of the situation. Transportation will notify the parents and arrangements will be made to meet EMS at the designated hospital. 5. Transportation will notify the building nurse/health specialist of the incident. 6. Nurse will notify the parents for follow-up. The incident is to be documented in the student s health file. Extracurricular Activities 1. The student will notify the coach, director, teacher or supervising adult that an allergic reaction is occurring and he/she has an auto-injector ( Epi-pen) and has permission to use it. 2. The adult will stay with the student during the administration of the auto-injector will be called and the adult will inform EMS of the location of the activity. 4. Parents will be notified and arrangements will be made to meet EMS at the designated hospital. The auto injector (Epi-pen) will be carried (designated area) *Additional Information **Parent or student should notify the school nurse/health specialist if any information on the student s condition changes during the school year. *** Parents/Guardian relinquish the Indian Hill Exempted Village School District of all liability related to the misuse of the auto-injector by their child, other students and/or non-medical district personnel.

4 I give my permission for my child to carry his/her auto injector (Epi-pen) at school. I understand that he/she must follow the rules required for self-medication with an auto injector at school: Demonstration of correct use of auto injector Agree to never share auto injector with anyone Agree to keep auto injector in designated area Agree to contact supervising adult when allergic reaction occurs, prior to administering auto injector. Parent/Guardian Signature Date Assessment of Student s Knowledge of and Responsibility for Control of Food Allergy Reaction (interview to be done by school nurse/health specialist) 1. What food are you allergic to? 2. Have you ever had an allergic reaction to this food? 3. If so, what reaction did you have? 4. When was your last reaction? 5. Do you know what causes this to happen? 6. Have you ever used an auto injector (Epi-pen)? 7. Do you want to carry your own auto injector? 8. Why? A. Student has demonstrated to the nurse/health specialist the correct use of the auto injector (Epi-pen). B. Student agrees never to share auto injector with anyone. C. Student determines where to store auto injector. Location is (Staff will be made aware of the location) D. Student agrees to contact supervising adult at the onset of an allergic reaction. Student s Signature Date Nurse/ Health Specialist Signature Date Physician Approval for Student to Carry and Use Auto injector (Epi-pen) In order for a student to possess and use an auto injector (Epi-pen) for an allergic reaction to food he/she must have written approval from the student s physician as well as the

5 parents or guardian. The student must demonstrate to the school nurse/health specialist the appropriate use of the auto injector. Signed approvals will be kept in the building clinic. Physician (please attach orders or fill out the following and sign) Name of student Address of student Name of medication to be carried and used. Date for self-carry orders to begin. Any special instructions? Physician s signature Date Physician s phone number KC/08

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