Mcps Form 525-14 Release And Indemnification Agreement Agreement For Epinephrine Auto Injector - Maryland, Montgomery County Public Schools

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MONTGOMERY COUNTY PUBLIC SCHOOLS
EMERGENCY CARE FOR THE MANAGEMENT OF A
MONTGOMERY COUNTY DEPARTMENT OF
STUDENT WITH A DIAGNOSIS OF ANAPHYLAXIS
HEALTH AND HUMAN SERVICES
Release and Indemnification Agreement for
Rockville, Maryland 20850
Epinephrine Auto Injector
PART I: TO BE COMPLETED BY THE PARENT/GUARDIAN
I hereby request and authorize Montgomery County Public Schools (MCPS) and Montgomery County Department of Health and
Human Services (DHHS) personnel to administer an epinephrine auto injector as directed by the authorized prescriber (Part II, below).
I agree to release, indemnify, and hold harmless MCPS and DHHS and any of their officers, staff members, or agents from lawsuit,
claim, demand, or action against them for administering prescribed medication to this student, provided MCPS and DHHS staff are
following the authorized prescriber’s orders as written in Part II. I am aware that the injection may be administered by a trained,
unlicensed staff member. I have read the procedures outlined on the back of this form and assume the responsibilities as required.
I understand that the rescue squad (911) will always be called when an epinephrine auto injector is administered,
whether or not the student manifests any symptoms of anaphylaxis.
Student Name
/
/
Birthdate
School Name
-
-
/
/
Signature, Parent/Guardian
Phone Number
Date
PART II: TO BE COMPLETED BY THE AUTHORIZED PRESCRIBER
In accordance with Maryland State Regulations, the epinephrine auto injector may be administered by unlicensed staff (DHHS
school nurse or MCPS employee) that are trained by the School Community Health Nurse (SCHN). Unlicensed staff are not allowed
to wait for the appearance and observe for the development of symptoms for students with an authorized prescriber’s order to
administer the epinephrine auto injector.
1.
Name of medication: epinephrine auto injector (e.g. EpiPen, Auvi-Q, generic, etc.) ________________________________
• Epinephrine auto injector will not be accepted for the management of asthma.
2.
Diagnosis: Anaphylaxis / Severe allergic reaction to: _______________________________________________________________
_________________________________________________________________________________________________________________
3.
Authorized Prescriber Order: Times to be given: Check (✔) all that apply:
□  If insect stings (bees, wasps, hornets, yellow jackets)
□  Ingestion of (specify):
□  If other known or unknown allergen(s) (explain): _____________________________________________________________
_________________________________________________________________________________________________________________
4.
Route of administration for epinephrine auto injector: Intramuscularly (IM) into anterolateral aspect of the thigh.
5.
Dosage of medication: Check (✔) one: □  epinephrine auto injector 0.15 mg.
□  epinephrine auto injector 0.3 mg.
6.
Repeat dose in 10 minutes if rescue squad has not arrived.* □  Yes
□  No
*NOTE: For repeat dose, a second epinephrine auto injector must be ordered and brought to school.
7.
Side effects: Palpitations, rapid heart rate, sweating, nausea and vomiting: _________________________________________
THIS MEDICATION AUTHORIZATION IS EFFECTIVE
/
/
TO
/
/
Authorized Prescriber
-
-
/
/
Name—Print or Type
Phone Number
Original Signature, Authorized Prescriber
Date
SELF-CARRY/SELF-ADMINISTRATION OF EMERGENCY MEDICATION: AUTHORIZATION/APPROVAL
Self-carry/self-administration of emergency medication must be authorized by the prescriber and be approved by the school nurse
according to the state medication policy.
Prescriber’s authorization for self-carry/self-administration of emergency medication _________________________________
/
/
Signature, Authorized Prescriber
Date
School Nurse (RN) approval for self-carry/self-administration of emergency medication _______________________________
/
/
Signature, School Nurse
Date
PART III: TO BE COMPLETED BY THE PRINCIPAL OR SCHOOL NURSE
□    P arts I and II are complete, including signatures. It is acceptable if all items in Part II are written on the authorized
prescriber’s stationery/prescription blank.
□  Medication properly labeled by a pharmacist. Epinephrine auto injectors received: □  1 injector
□  2 injectors
Reviewed by
/
/
Signature, Principal/School Nurse
Date
MCPS Form 525-14, January 2017

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