Allergy Action Plan Template Page 2
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3PRINCE GEORGE COUNTY PUBLIC SCHOOLS
Allergy Action Plan
Page 2 of 3
__________________________________
_____________________
______________
Student’s Name:
School:
Teacher:
ALLERGY TO: _____________________________________________________________________________________
Does student have permission to carry and self-administer his/her own auto-injectable epinephrine?
________YES
________NO
If YES, where does student keep his/her auto-injector?
Plan for lunches and snacks if food allergy:
List foods to be substituted
__________________________________________________________________________
Does parent request separate table (allergen-free area) in the cafeteria?
________YES
________NO
May student purchase food at school and in the cafeteria?
________YES
________NO
Will parent provide snacks for each day? _________YES
________NO
for parties? ________YES
________NO
Other:
Plan for field trips:
Will parent attend field trips?
________YES
________NO
In the absence of the parent, the principal’s designee, who has been trained by a registered nurse in the administration of epinephrine,
will attend the field trip to provide care and administer epinephrine as ordered by licensed prescriber.
Other:
Plan for transportation to and from school:
Epinephrine will not be provided on the bus unless student has permission to carry and self-administer auto-injectable epinephrine.
Special accommodations shall be considered upon request of parent, guardian or physician. The Office of the Transportation
Department is informed of student’s allergic condition and has two-way radio communication capability with bus and car drivers.
Other:
Plan for sports and extracurricular activities:
Parent or guardian shall be responsible to inform coach, club sponsor, etc. of child’s allergic condition and any required treatment.
School nurse will communicate student’s allergy health information to coach, club sponsor, etc. upon written request of parent or
guardian.
Other:
Plan for communication of allergy information to school staff:
School nurse will communicate information about student’s allergic condition and treatment plan to school staff who need to know in
order to carry out the plan of care. Teacher shall be responsible to make available the information to substitute teacher.
Other:
Physician Signature: ____________________________________
Printed Name: _________________________________________
HSM 0001-0915
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