Emergency Action Plan And Order Form: Severe Allergy In School - Mecklenburg County Health Department
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1Mecklenburg County Health Dept
MECKLENBURG COUNTY HEALTH DEPARTMENT
SCHOOL HEALTH
Emergency Action Plan and Order: Severe Allergy in School
Student’s Name: ___________________________________
DOB: _____________________
Student’s Address: ______________________________________________________________
Student’s Phone #: _________________________ Student’s I.D: ________________________
Mother’s Name: __________________ Phone: Work _______________Cell _______________
Father’s Name: ___________________ Phone: Work _______________Cell _______________
Preferred Hospital: ______________________________________________________________
School: ______________________________ Teacher/Grade/Homeroom: __________________
□
□
School Year: _______________________________________ History of asthma:
Yes
No
Student is known to be highly allergic to: _______________________________
Student’s health care provider to complete the following information:
If ingestion of or contact with allergen is suspected; and/or if any of the
following symptoms occur:
o tingling/itching/swelling of the lips, tongue, mouth, throat
o sense of tightness in the throat
o hoarseness, hacking cough
o repetitive coughing
o hives/itchy rash
o swelling around the face or extremities
o nausea, abdominal cramps, vomiting, diarrhea
o shortness of breath
o blue color/paleness to lips or nails
o wheezing
o “passing out”
o low blood pressure
Give medications immediately
□
(Indicate dosage)
a.
Benadryl _______ mg by mouth
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(Check one)
b.
EpiPen 0.3 mg IM OR
EpiPen Jr. 0.15mg IM
If Epinephrine is given, call 911 immediately.
o Monitor vital signs.
o Call parent/notify school nurse/principal.
Other instructions:
Health Care Provider _______________________ Phone # _______________FAX #______________
Address:_____________________________________________________________________________
Health Care Provider’s signature: ___________________________________Date: _______________
(Please sign here to authorize this order and return to the School Health Program, MCHD, Hal
Marshal Annex, 618 North College Street, Charlotte, N.C. 28202 Fax: 704-432-2079 Attn:
School Health.)
Parent /Guardian Signature ________________________________________Date________________
School Health Nurse Signature _____________________________________Date________________
5/13 lp
CI 23
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