Colorado Allergy And Anaphylaxis Emergency Care Plan And Medication Orders Sheet Page 2
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2Student Name: ___________________________________________________ DOB: ___________________________________
TRAINED/DELEGATED STAFF MEMBERS
1. ______________________________________________
Room _________________
2. ______________________________________________
Room _________________
3. ______________________________________________
Room _________________
Self-carry contract on file.
Yes
No
Location of Medication: ________________________________
EXPIRATION DATE OF EPINEPHRINE AUTO INJECTOR: ________________________
NOTE: Consider lying on the back with legs elevated. Alternative positioning may be needed for vomiting (side lying,
head to side) or difficulty breathing (sitting)
Additional information
:_______________________________________________________________________________________
_____________________________________________________________________________________________
_________
_____________________________________________________________________________________________
_________
_____________________________________________________________________________________________
_________
_____________________________________________________________________________________________
_________
_____________________________________________________________________________________________
_________
_____________________________________________________________________________________________
_________
_____________________________________________________________________________________________
_________
C.R.S. 22-2-135(3)(b)
2/2015
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