Banner Christian School Rev. 6-17-22

5831 Courthouse Rd Chesterfield, Virginia 23832 Phone: 804-276-5200 Fax: 804-276-7620

www.bannerchristian.org

EPINEPHRINE AUTHORIZATION

FOR USE WITH ANTIHISTAMINE AUTHORIZATION AND ALLERGY ACTION PLAN

PART I – TO BE COMPLETED BY PARENT OR GUARDIAN

I hereby request school MAT personnel or other designated school personnel to administer an epinephrine injection as directed by this authorization. I agree to release, indemnify, and hold harmless the designated school personnel, or agents from lawsuits, claim expense, demand or action, etc., against them for administering these injections, provided the designated school personnel comply with the Licensed Healthcare Provider or parent/guardian orders set forth in accordance with the provision of Part II below. I am aware that the injection may be administered by a specifically authorized and trained non-health professional. I have read the procedures outlined on the back of this form and assume responsibility as required.

I understand that emergency medical services (EMS) will ALWAYS be called when Epinephrine is given, whether or not the students manifests any symptoms or anaphylaxis, and that the student will be required to go to the Emergency Room via Rescue Squad.

Student Name (last, first, middle):_____________________________________________________ Date of Birth:___________________ Grade: ______ School Year:____________________ Allergies:________________________________________________________________________

PART II – TO BE COMPLETED BY LICENSED HEALTH CARE PROVIDER WITH NO ABBREVIATIONS

Emergency Epinephrine injections may be administered by authorized and trained non-health professionals. These persons are prepared by licensed health care personnel to administer the injection. For this reason, only pre-measure doses of Epinephrine (auto injector) may be given.

After report of student exposure to (specific allergens)_____________________________________________________________________ Route of exposure: ___ Ingestion ___ Skin Contact ___ Inhalation ___ Insect bite or sting

The following action will be taken: (check one only)

___ The following injectable epinephrine dosage will be given IMMEDIATELY as prescribed below

___ The following injectable epinephrine dosage will be given as noted below and as detailed on the attached Allergy Action Plan, in conjunction with the attached Antihistamine Authorization Form.

Check appropriate medication/dosage/instructions:

___ EpiPen 0.3 mg ___ Twinject 0.3 mg ___ Adrenaclick 0.3 mg ___ Auvi-Q 0.3 mg

___ Give the pre-measured ode of 0.3 mg epinephrine 1:1000 aqueous solution (0.3cc) by auto injection intramuscularly in anterolatural thigh

___ Repeat the dose in 15 minutes if EMS has not arrived. (two pre-measured does will be needed at school)

___ EpiPen Jr. 0.15 mg ___ Twinject 0.15 ___ Adrenaclick 0.15 mg ___ Auvi-Q 0.15 mg

___ Give the pre-measured ode of 0.15 mg epinephrine 1:2000 aqueous solution (0.3cc) by auto injection intramuscularly in anterolatural thigh

___ Repeat the dose in 15 minutes if EMS has not arrived. (two pre-measured does will be needed at school

COMMON SIDE EFFECTS: Increased heart rate, stronger or irregular heartbeat, sweating, nausea, vomiting, feeling weak, feeling anxious

Effective Date:_______________ If the student is taking more than one medication at school, list sequence the inhalers are to be taken.

Start Date: ____________ End Date:____________ Date Parent to Pick-up from School: ___________

OVER

PART II – TO BE COMPLETED BY LICENSED HEALTH CARE PROVIDER WITH NO ABBREVIATIONS (continued)

Check appropriate statement: ___ The student’s epinephrine auto injectors are to be kept in the school health office or other school approved location. ___ I certify that this child has a medical diagnosis of severe allergic reactions, has been trained in the safe use of the prescribed medication(s) and is judged to be capable of safely carrying and self-administering an epinephrine auto injector in school. The MAT personnel or appropriate school staff should be notified anytime the medication/injector is used. This child understands the hazards of sharing medications with others and has agreed to refrain from this practice. The student has medical permission to self-carry and self-administer epinephrine during school hours, subject to MAT trained personnel approval. A second dose is to be kept in the school health office or other designated school location. The student is aware that the school may withdraw permission to possess and self-administer epinephrine at any point during the school year is the student has abused the privilege of possession/sef-administration or the student is not safely, reliably and effectively managing this medication.

__________________________________________ _______________________________________ ____________________ ____________ Licensed Health Care Provider (PRINT) Licensed Health Care Provider (Signature) Phone Number Date

________________________________________ _______________________________________ ____________________ ____________ Parent/Guardian (PRINT) Parent/Guardian (Signature) Phone Number Date _________________________________________ ___________ Student (Signature) Date

PART III – TO BE COMPLETED BY MAT PERSONNEL

Check as appropriate:

___ Parts I and II are complete, including signatures. (It is acceptable if all items in Part II are written on the LHCP stationery or prescription pad.)

___ Auto injectors are appropriately labeled and in original packaging.

_____________ Date by which any unused auto injectors are to be collected by the parent. (Within one week after expiration of the physician order or the last day of school)

If applicable, I have reviewed the proper use of an auto injector with the student and I ___ agree ___ disagree that the student should self-carry epinephrine in school.

________________________________________ _______________________________________ ____________ MAT Personnel (PRINT) MAT Personnel (Signature) Date