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Regional School District No. 16

Beacon Falls/Prospect Connecticut

Authorization for Epinephrine/Benadryl Administration by School Personnel or Self-Administration

Connecticut State Law requires a written order from an authorized prescriber (MD, DDS, OD, DO, PA, APRN) and parent/legal

guardian/eligible student (18 years old or emancipated minor) authorization for both prescription and non-prescription medications. All

medications shall be delivered to the school by the parent, guardian, eligible student or other responsible adult. The medication must be

stored in the original labeled container as dispensed from the pharmacy.

Name of Student: ______________________________________________ DOB: ______________________ Grade: ________

Known Allergies: _________________________________________________________________________________________

If student ingests or thinks he/she has ingested the above named food or has been stung by above named insect: _______________

________________________________________________________________________________________________________

Please note desired order(s) by number :

Circle desired epinephrine injector dosage:

____________ Observe patient for symptoms of anaphylaxis***

____________ Administer Benadryl ______ tsp. Swish and swallow

before

____________ Administer epinephrine

symptoms occur -

EpiPen/_____________ 0.15 mg.

0.3 mg

____________ Administer epinephrine

symptoms occur

EpiPen/ _____________ 0.15 mg.

0.3 mg

____________ Administer ____________________________________________________________________

9-1-1 will be called for anyone with anaphylactic symptoms or EpiPen administration.

***Symptoms of Anaphylaxis may include: Chest tightness, cough, shortness of breath, wheezing, tightness in throat, difficulty

swallowing, hoarseness, swelling of lips, tongue or throat, itching mouth or skin, hives or swelling, stomach cramps, vomiting or diarrhea,

dizziness or fainting.

Side Effects and Management: ______________________________________________________________________

Special Instructions:

_________________________________________________________________________________________

“yes”

Student is capable of self-administration of EpiPen:

Yes

No (If

, prescriber training is required.)

Student has been trained in self-administration of this medication in prescriber’s office:

Yes

Dates of Administration: From

To:

: ___________

_______________

Signature

(Physician / Authorized Prescriber) Date: _____________

Address: _____________________________________________________________ Phone: _______________________________

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Parent / Legal Guardian or Eligible Student Authorization

I hereby give permission for qualified personnel to administer/my child to self-administer/the medication above as ordered by his

or her authorized prescriber. I understand that if my child is authorized for self-administration any misuse of this medication will

result in disciplinary consequences following Regional School District No.16 Board of Education policy and procedure. I

understand that this medication will be destroyed if it is not picked up within one week following termination of the order or by

the last day of school.

I give permission for the release and exchange of information between the school nurse and authorized prescriber necessary to

ensure the safe administration of such medication.

Signature of Parent/ Legal Guardian/Eligible Student: ___________________________________________________________

Date:

Home Phone: ________________________________ Cell Phone: ________________________________

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School Nurse Authorization

Self-administration of medication may be authorized by the prescriber and parent/legal guardian/eligible student and approved

by the school nurse in accordance with Regional School District No.16 Board of Education policy/procedure.

School Nurse approval for Self-Administration: { Yes

{ No:

________________________________________

_________________________________________

____________________________________

RN Signature

Date:

Authorization For Epinephrine/benadryl Administration By School Personnel Or Self-Administration Form - Regional School District No.16

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