Training Checklist Template For Unlicensed Personnel - Epinephrine Auto-Injector (Eai)
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1Epinephrine Auto-Injector (EAI)
Training Checklist for Unlicensed Personnel
This review is for:
Adrenaclick/Epinephrine Auto-injector, USP (Generic version)
Auvi-Q™
Epi-Pen®/ Epi-Pen Jr.®
Trainer Name:
Trainer Title : RN
NP
PA
MD/DO Collaborative Provider Designee
School Name:
School Staff Member Name:
Trainer
Date
Review Date/
Knowledge Check for Administering EAI
Initials
Trainer Initials
Staff member provides copy of Allergy Management and
Epinephrine Training post-test which indicates 100% accuracy.
Accurately reads and follows an emergency care plan (ECP)
Accurately reads auto-injector label and identifies dose needed
Trainer
Date
Review Date/
Skills Check for Administering EAI
Initials
Trainer Initials
Calls/instruct someone to call 911 and activate school emergency
response plan
1. Checks expiration date and make sure solution is clear
2. Pulls off end cap, remove safety guard if brand requires it
3. Places tip of injector on outer thigh at 90° angle.
(through clothing if needed)
4. Presses hard into thigh until click or verbal prompt is heard
5. Holds in place for 5 or 10 seconds (dependent on brand),
then removes and massage injection site for 10 seconds
6. Place used auto-injector into protective case if directed by
manufacturer
7. Instructs victim to lie down until EMS arrives
8. Disposes of used auto-injector as indicated in school plan
9. Documents use as indicated in school plan
10. Informs required individuals as indicated in school plan
This training is valid for the school year in which it is given. Training should be renewed annually.
This record should be maintained for one year.
Trainer Signature: _________________________________________________
Staff Member (Designee) Signature: _____________________________________
This sample resource is located at
– epinephrine page–
2/15
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Parent category: Life