The Public Schools of Verona, New Jersey

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1 The Public Schools of Verona, New Jersey Procedure for Epi-Pen administration in the Verona Schools 1. The school nurse will provide the parent with the paperwork that must in place for epinephrine administration. This paperwork must be filed with nurse prior to the 1st day of classes. The nurse will verify the doctor s orders and have the paperwork reviewed by the school physician. 2. The parent will provide the nurse with the proper medication. If the student is to self administer, they must carry the medication with them at all times and keep a back up in the nurse s office. 3. If the student self administers, the school nurse will have the student demonstrate his/her knowledge of administration to the nurse. 4. The school nurse will ask faculty members to volunteer to be trained as delegates for the student. She will train these delegates according to standardized protocols established by the Department of Education in consultation with the Department of Health and Senior Services. 5. The school nurse will ensure that the delegate knows where the auto injector is stored and memorialize this information in writing. The school nurse will have the delegated sign off on his/her training. These files will be stored in the nurse s office. 6. It is the responsibility of the parent to inform the school nurse of activities that the student will be participating in /attending that are school sanctioned but not during regular school hours. This would include athletic teams that the student might be a part of. It is also the responsibility of the parent to make sure that the student who self administers has the Epi-Pen with them at all times. 7. The school nurse will prepare an Individualized Health Care Plans or a 504 as appropriate, along with an individualized Emergency Care Plan and ensure that key personnel know where these are maintained. 8. The parent will provide a notarized, signed copy of the Parent Release and Indemnification form.

2 The Public Schools of Verona, New Jersey Parent Form for Allergy Emergency Treatment Student Name Grade/HR Parents/Guardians A current single dose Epinephrine auto-injector must be provided to the school for your child s use. Two single doses must be provided to the nurse if your healthcare provider has ordered a repeat dose to be given. All antihistamines and epinephrine must be brought to school by an adult and be provided in the original container. Checklist for parent use: Please initial those that apply to your student I have supplied the school nurse with completed and signed medication orders. (initial) One spare Epinephrine auto-injector device with valid expiration date was supplied to the school nurse for inclusion in the emergency kit for delegate to administer as needed. (initial) When my child is in a club, staying after school, on a field trip, involved in sports or other activity outside of the building, I will inform the person in charge of that activity/event of my child s allergy. (initial) Additional for students with Self administer orders: Epinephrine auto-injector was supplied to my child with a valid expiration date Expiration: date / / (initial) I have reminded my child to keep one dose of epinephrine with him/her at all times. (initial) I have reminded my child to keep one dose of antihistamine with him/her at all times. or Antihistamine is not prescribed. (initial) **PLEASE NOTE: The School Nurse by law may administer any medication with medical provider s orders and parental consent, but trained nonmedical designees, who may give emergency treatment in the School Nurse s absence, are NOT permitted by law to administer any medications other than epinephrine via auto-injector mechanism. **PLEASE COMPLETE BOTH SIDES OF FORM!!

3 Select one to sign and date. 1. I verify that my child has a potentially life threatening illness and has been instructed in self- administration of the prescribed medication in a life threatening situation. I hereby give permission for my child to self administer prescribed medication. I further acknowledge that the Verona Public schools shall incur no liability as a result of any injury arising from the self-administration of medication by my child. If procedures specified by NJ law and Verona School District policy are followed, I shall indemnify and hold harmless the Verona School District and it s employees or agents against any claims arising out of self administration of medication by my child. Signature of Parent/Guardian Date 2. I verify that my child has a potentially life threatening illness and is unable to self-administer the prescribed medication in a life threatening situation. I hereby request the school nurse or delegate (if applicable) to administer the prescribed medication to my child. I further acknowledge that the Verona Public schools shall incur no liability as a result of any injury arising from administration of the medication to my child. If procedures specified by NJ law and Verona School district are followed, I shall indemnify and hold harmless the Verona school District and it s employees or agents against any claims arising out of administration of medication to my child. Signature of Parent/Guardian Date In addition, an indemnification and release form must be signed, notarized and returned to the school nurse no matter which of the above you check. TREATMENT BY A DELEGATE WHEN A NURSE IS NOT PRESENT: N.J.S.A. 18A: directs that the school nurse shall designate additional employees of the school district who volunteer to administer epinephrine to a student who has anaphylaxis when a nurse is not physically present at the scene. A Delegate may give one dose of auto-injector epinephrine. After giving epinephrine, call 911, parent, and healthcare provider. Please sign I understand that under NJ state law, a trained delegate will be assigned to administer epinephrine to my child in the absence of a school nurse. Antihistamines may not be given by a delegate. In the absence of a school nurse, any antihistamine order will be disregarded and epinephrine will be administered by a trained delegate. Parent Signature Date School Use Only Signature of Principal Date Signature of School Nurse Date

4 Verona Public Schools Verona, New Jersey Parent Release and Indemnification This Release, dated is given by the Releasers (Names of Parent/Guardian) on behalf of their minor child, _ (referred to as Releasors ) (Name of Student) residing at to the Board of Education of the School District of (Address) Verona, having offices at 121 Fairview Avenue, Verona, New Jersey (referred to as Board ). WHEREAS, (hereinafter Student ) has a medical condition that (Name of Student) requires the possible need for immediate administration of epinephrine; and WHEREAS, Releasors have provided to the school an Epi-Pen in the event that immediate administration of epinephrine is necessary and have approved the selection of and understand that certain designee(s) may administer the Epi-Pen in the event that the school nurse is unavailable; The parties agree as follows: 1. The foregoing recitals are incorporated by reference herein; 2. Releasers understand that if the procedures specified in the standardized training protocols established by the Department of Education in consultation with the Department of Health and Senior Services (currently entitled Protocol and Implementation for the Emergency Administration of Epinephrine by a Delegate Trained by the School Nurse ) are followed, the Board, its Members, its Employees, and its Agents shall have no liability as a result of any injury arising from the administration of the Epi-Pen to student. Releasors specifically agree for themselves, their heirs, successors and assign, to release irrevocably and unconditionally and discharge the Board, its Members, its Employees and its Agents of and from any and all obligations, claims, demands, judgments, claim for attorney fees, claims for contribution and/or in tort, contract, by statute, or on any other basis, whether in law or equity, which Releasors or Releaser s estate might otherwise have or have had from the beginning of time to the date Releasors sign this Agreement. 3. Releasers shall indemnify and hold harmless the Board of Education, its Members, Employees and its Agents against any claims arising out of the administration of the Epi-Pen to student. 4. This Release is made for good and valuable consideration hereby acknowledged. Releasors agree that Releasers will not seek anything further from Releasees. Signed and sworn to before me on: (Date) (Notary Public) (Name of Parent/Guardian) _ (Name of Parent/Guardian)

5 Medical Department Verona Public Schools Physician's Orders for Allergy Emergency Treatment Student Name: Date of Birth: Teacher: Grade: The above student is allergic to: Previous episode of anaphylaxis: Yes No MEDICATIONS Antihistamine: Name Dose Give antihistamine for the following checked symptoms: Contact with allergen, but no symptoms Skin - hives, Itchy rash, extremity swelling Lips - itching, tingling, burning, or swelling of lips Head/neck - swelling of tongue, mouth, or throat, hoarseness, hacking, cough, tightening of throat, Gut - abdominal cramps, nausea, vomiting, diarrhea Lungs- repetitive cough, wheezing, shortness of breath Heart - thready pulse, low blood pressure, fainting, pale or bluish skin Other Epinephrine: EpiPen EpiPen, Jr. Other Give epinephrine for the following checked symptoms: Contact with allergen, but no symptoms Skin - hives, itchy rash, extremity swelling Lips - itching, tingling, burning, or swelling of lips Head/neck - swelling of tongue, mouth, or throat, hoarseness, hacking cough, tightening of throat Gut - abdominal cramps, nausea, vomiting, diarrhea Lungs- repetitive cough, wheezing, shortness of breath Heart - thready pulse, low blood pressure, fainting, pale or bluish skin Other Choose one administration order: Give Antihistamine only. [] Give Epinephrine only. * (Delegate will be assigned.) Give Antihistamine and Epinephrine at the same time. Give Antihistamine first, observe for further symptoms and give Epinephrine PRN. *PLEASE NOTE: In the absence of the school nurse, any antihistamine order will be disregarded and a trained delegate will give the auto-injectable dose of epinephrine. This student has been trained and is capable of self-administration of the following medications: Epinephrine - single unit dose Antihistamine - single unit dose This student is not capable of self-administration of the medications named above. Physician's Signature Phone Number Date (STAMP)

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