Report Of Epinephrine Administration Form - Haywood County Schools Page 2
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2Haywood County Schools
15. Location of epinephrine storage: Office
Other
specify ___________________________________________________
16. Epinephrine administered by:
RN
Self
Other
If epinephrine was self-administered by a student at school or a school-sponsored function, was the student formally trained?
Yes
If known, date of training ___________________
No
Did the student follow school protocols to notify school personnel and activate EMS?
Yes
No
NA
If epinephrine was administered by other, please specify___________________________
Was this person formally trained? Yes
Date of training _________________
No
Don’t know
17. Time elapsed between onset of symptoms and communication of symptoms: _______________________________________________minutes
18. Time elapsed between communication of symptoms and administration of epinephrine: _______________________ _______________minutes
Parent notified of epinephrine administration: (time)
19. Was a second epi-pen dose required? Yes
No
Unknown
If yes, was that dose administered at the school prior to arrival of EMS? Yes
No
Unknown
Approximate time between the first and second dose ___________________________________
Biphasic reaction: Yes
No
Don’t know
Disposition
20. EMS notified at: (time) _______________________________
Transferred to ER: Yes
No
Unknown
If yes, transferred via ambulance
Parent/Guardian
Other
Discharged after _______ hours
Parent: At school
Will come to school
Will meet student at hospital
Other:
21. Hospitalized:
Yes
If yes, discharged after _________ days
No
Name of hospital:
22. Student/Staff/Visitor outcome: ___________________________________________________________________________________________
School Follow-up
23. Did a debriefing meeting occur?
Yes
No
Did family notify prescribing MD? Yes
No
Unknown
24. Recommendation for changes: Protocol change
Policy change
Educational change
Information sharing
None
25. Comments (include names of school staff, parent, others who attend debriefing): __________________________________________________
___
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Completed by: ___________________________________________________________
Date: ___________________________________
Title: ___________________________________________________ Phone number: (_______) ________ - ____________ Ext.: _________
Email : ___________________________________________________
School: ________________________________________________________________________________________________________
School address: _______________________________________________________________________________________________________
Rev 3/14
Please complete all pages.
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