Allergy Action Plan Template (Page 3 of 3) in pdf

PRINCE GEORGE COUNTY PUBLIC SCHOOLS

Allergy Action Plan

Page 3 of 3

I, ____________________________________________, parent or legal guardian of __________________________________,

request that the principal’s designee at _____________________________________ School administer the prescribed

medication and provide care to my child as indicated on this Allergy Action Plan. I give the school nurse, principal, and/or

principal’s designee permission to contact the licensed prescriber if necessary. In signing this form, I am agreeing to hold the

school and its personnel free from any legal action that might arise from this arrangement.

I also understand that I am to abide by the school division regulations as stated below:

•

Parent or guardian must bring medication into school. All medication brought to school must be delivered to the office or clinic

immediately. Medication cannot be transported on buses or by students.

•

Prescription medication must have a current prescription label that corresponds with the written authorization.

•

Any changes in an original medication authorization require a new written authorization and corresponding change in the

prescription label.

•

Parent or guardian is responsible for supplying medications and any equipment required to administer medications or provide

special medical care.

•

Expired medication will not be administered to students. Parent or guardian is responsible to replace expired medication

immediately. Expired medication that has not been picked up by parent or guardian within 2 (two) weeks of notification will

be discarded.

•

Left over medication that has not been picked up by parent or guardian at the end of the school year will be discarded.

Students with a diagnosis of anaphylaxis (severe allergic reaction) may possess and self-administer auto-injectable epinephrine during

the school day, at school-sponsored activities, and while on the bus or other school property provided the following conditions are met:

 Written consent from a parent and written notice from licensed prescriber that identifies the name, dosage and frequency

of medication and circumstances which warrant such medication to be self-administered;

 Physician confirmation that student demonstrates ability to safely and effectively self administer medication;

 Individualized health care plan including emergency procedures for any life-threatening conditions (completion of this

Allergy Action Plan meets such requirement);

 Permission to possess and self-administer auto-injectable epinephrine shall be effective for one year, defined as 365

calendar days, and must be renewed annually.

 Parent or guardian will be notified by a school official before any limitations or restrictions are imposed upon a student’s

possession and self-administration of auto-injectable epinephrine.

 It is the student’s responsibility to notify a teacher or school health official after self administering medication.

I approve this Allergy Action Plan for my child. I give permission to share information about my child’s allergic condition with the

school nurse, teachers, principals, office staff, guidance, bus driver/transportation, cafeteria monitor, and food services as appropriate.

Parent/Guardian Signature ______________________________________________ Date _______________________

Parent/Guardian PRINTED Name _____________________________________________________________________

Home Phone ______________________ Work Phone ____________________ Cell Phone _____________________

School Use:

Health care plan information provided by __________________________________________ to the following staff:

Names of Persons and Date

_______________________________________________

HSM 0001-0915

Allergy Action Plan Template Page 3

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