Jefferson township middle school

JEFFERSON TOWNSHIP
PUBLIC SCHOOLS
AUTHORIZATION OF EMERGENCY TREATMENT
(All Areas Must Be Completed)
________________________________________ is allergic to: ______________________
Allergic Reaction Risk Level: _____ Low _____ Moderate _____ High
If you suspect that a food allergen has been ingested (or insect sting), immediately determine the symptoms and treat the
reaction as follows:

Symptoms:
Give Medication checked “X”
Mouth
Itching, tingling, or swelling of lips, tongue, mouth
Benadryl
Epinephrine
Skin
Hives, swelling on face or extremities, itchy rash
Benadryl
Epinephrine
Gut
Nausea, abdominal cramps, vomiting, diarrhea
Benadryl
Epinephrine
Throat
Tightening of throat, hoarseness, hacking cough
Benadryl
Epinephrine
Lung
Shortness of breath, repetitive coughing, wheezing
Benadryl
Epinephrine
Heart
Thready pulse, passing out, fainting, pale, blueness
Benadryl
Epinephrine
General:
Panic, sudden fatigue, chills, fear of impending doom
Benadryl
Epinephrine
If a food allergen has been ingested, but no symptoms:
x Benadryl
Epinephrine
Other_________
If a reaction is progressing (several of the above areas affected)
x Benadryl
x Epinephrine

Medication Dosages: Nurses Only
Antihistamine: (liquid diphenhydramine, Benadryl™):
Give __________________________ Teaspoon(s) _______cc (_______mg) by mouth.
NURSE OR DELEGATE:
Epinephrine:
EpiPen™: Epi-Pen ______ Epi-Pen Jr. _____ (______mg) injected once into upper outer thigh
Epinephrine injection many need to be repeated if the child’s symptoms persist or get worse.
Call 911 and phone number: ________________________________
State that the child had a severe allergic reaction, and additional epinephrine doses may be needed.
Additional contact information:
Nearest Hospital:

Name: ______________________________ Phone: ______________ Address: _________________
Allergist Name: _____________________________ Phone: _________________________
Pediatrician Name: __________________________ Phone: __________________________
Parent’s Name (other contacts) and Contact Numbers:
Name: _________________________________________
Phone (1) ___________________________________ Phone (2) _______________________
Name: _________________________________________
Phone (1)_____________________________________Phone (2)
Other allergies, medication allergies, medical conditions: _______
Approximate Weight ____lbs.
DO NOT HESITATE TO ADMINISTER MEDICATION OR TAKE THE CHILD TO A MEDICAL FACILITY EVEN
IF THE PARENTS CANNOT BE REACHED!
This student may _____ may not _____ self-administer epinephrine auto injector.
Medication Located: _____ Nurse’s Office ______Classroom _____With Student_____Other (Specify)

______________________
__________________
____
________________
Physician’s Printed Name Physician’s Signature
Date
Parent’s Signature

TRAINED DELEGATE _________________________________ Room #________________
JGK-2010

Source: http://www.jefftwp.org/district/Mailing/Mailing2011/FORM-EpiPen%20Authorization%20of%20Medical%20Treatment.pdf