Illinois Food Allergy Emergency Action Plan And Treatment Authorization
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2ILLINOIS FOOD ALLERGY EMERGENCY ACTION PLAN
Child’s
AND TREATMENT AUTHORIZATION
Photograph
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NAME:
D.O.B:
TEACHER:
GRADE:
ALLERGY TO:
Asthma: Yes (higher risk for a severe reaction)
No
Weight: ______ lbs
ANY SEVERE SYMPTOMS AFTER SUSPECTED
INJECT EPINEPHRINE
INGESTION:
IMMEDIATELY
LUNG: Short of breath, wheeze, repetitive cough
− Call 911
HEART: Pale, blue, faint, weak pulse, dizzy, confused
− Begin monitoring (see below)
THROAT: Tight, hoarse, trouble breathing/swallowing
− Additional medications:
MOUTH: Obstructive swelling (tongue)
− Antihistamine
− Inhaler (bronchodilator) if asthma
SKIN: Many hives over body
*Inhalers/bronchodilators and antihistamines are
Or Combination of symptoms from different body areas:
not to be depended upon to treat a severe
reaction (anaphylaxis) Use Epinephrine.*
SKIN: Hives, itchy rashes, swelling
**When in doubt, use epinephrine. Symptoms can
GUT: Vomiting, crampy pain
rapidly become more severe.**
MILD SYMPTOMS ONLY
GIVE ANTIHISTAMINE
Mouth: Itchy mouth
− Stay with child, alert health care professionals and parent.
Skin: A few hives around mouth/face, mild itch
Gut: Mild nausea/discomfort
IF SYMPTOMS PROGRESS (see above), INJECT EPINEPHRINE
If checked, give epinephrine for ANY symptoms if the allergen was likely eaten.
If checked, give epinephrine before symptoms if the allergen was definitely eaten.
MEDICATIONS/DOSES
EPINEPHRINE (BRAND AND DOSE):
_________________________________________________________
ANTIHISTAMINE (BRAND AND DOSE):
_________________________________________________________
Other (e.g., inhaler-bronchodilator if asthma):
_________________________________________________________
MONITORING: Stay with the child. Tell rescue squad epinephrine was given. A second dose of epinephrine can be
given a few minutes or more after the first if symptoms persist or recur. For a severe reaction, consider keeping child
lying on back with legs raised. Treat child even if parents cannot be reached.
Student may self-carry epinephrine
Student may self-administer epinephrine
CONTACTS: Call 911 Rescue squad: (_____)_____________________
Parent/Guardian: ___________________________________
Ph: (____)_________________________________________
Name/Relationship: _________________________________
Ph: (____)_________________________________________
Name/Relationship: _________________________________
Ph: (____)_________________________________________
Phone:
_________
Date:__________________________
Licensed Healthcare Provider Signature:
(Required)
I hereby authorize the school district staff members to take whatever action in their judgment may be necessary in supplying emergency medical
services consistent with this plan, including the administration of medication to my child. I understand that the Local Governmental and Governmental
Employees Tort Immunity Act protects staff members from liability arising from actions consistent with this plan. I also hereby authorize the school district staff
members to disclose my child's protected health information to chaperones and other non-employee volunteers at the school or at school events and field trips
to the extent necessary for the protection, prevention of an allergic reaction, or emergency treatment of my child and for the implementation of this plan.
Date:
__________
_
Parent/Guardian Signature:
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