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NORTH CAROLINA MEDICAL CARE COMMISSION

CREDENTIAL OF TRAINING FOR THE USE OF EPINEPHRINE

FOR TREATMENT OF ADVERSE REACTIONS TO AGENTS THAT MIGHT CAUSE ANAPHYLAXIS

Applicant’s Name_____________________________________________________________________________

Address_____________________________________________________________________________________

Date of Birth____________________________________

Applicant’s Statement: I have not violated any law or regulation enacted under the provisions of Chapter 90

of the General Statutes of N. C.

Date__________________ Signature___________________________________________________________

FOR RECREDENTIAL APPLICANTS ONLY

Please mark NA in the appropriate space for questions 1 and 2 if you have not had any activity in administering epinephrine.

1. How many persons did you see having an allergic reaction during your previous credential period?

____________

2. How many persons did you administer epinephrine to as a result of an allergic reaction during your credential period? ____

3. Briefly describe the outcome of the person(s) who received epinephrine as a treatment for an allergic reaction as a result of

your training and credential. (Please include the person’s condition, your actions in addition to administering epinephrine,

and the person’s outcome, i.e. hospitalization, etc. (Use reverse side of form)

This will certify that the above named individual, who to my knowledge, is of good moral character, has completed all phases

of a training program teaching the administration of epinephrine to persons who suffer adverse reactions to agents that might

cause anaphylaxis. This training program was conducted by me or my designee and meets the training guidelines set forth by

the North Carolina Medical Care Commission. I hereby recommend that the North Carolina Medical Care Commission approve

the above named individual to administer epinephrine to persons who suffer adverse reactions to agents that might cause

anaphylaxis in the absence of physicians or other practitioners authorized to administer this treatment; and I also certify that

the above named individual has been advised of the legal implication involved in administering such treatment.

Physician’s Name____________________________________ N. C. License No.__________________________

Address_____________________________________________________________________________________

Date__________________ Signature___________________________________________________________

North Carolina Medical Care Commission Approval

The above named applicant is approved to administer epinephrine to persons who suffer adverse reactions to agents

that might cause anaphylaxis. This approval shall be effective for four years from the date indicated below.

Date__________________

________________________________________________________

North Carolina Medical Care Commission

Revised (January 2009)

DHHS/DHSR/EMS 4904

Credential Of Training For The Use Of Epinephrine For Treatment Of Adverse Reactions To Agents That Might Cause Anaphylaxis Form - North Carolina Medical Care Commission