Severe Allergic Reaction Care Plan Template (2015) Page 2
Download a blank fillable Severe Allergic Reaction Care Plan Template (2015) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Severe Allergic Reaction Care Plan Template (2015) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Select Year
Severe Allergic Reaction Care Plan
Student Name: ____________________________________
Individual Considerations
CLASSROOM—For Food Allergy Only
Student is only allowed to have food approved by parent.
Middle school or high school student will be making his/her own decisions regarding food.
Alternative snacks will be provided by parent/guardian to be kept in the classroom.
Parent/guardian should be advised of any planned parties as early as possible.
Classroom projects should be reviewed by the teaching staff to avoid specified allergens.
Other (specify): _____________________________________________________________________________________
CAFETERIA—
NO Restrictions
Student will sit at a specified allergy table.
Student will sit at the general classroom table cleansed according to standard procedure guidelines prior to students arrival.
Specify additional guidelines:
Cafeteria staff and supervisors should be alerted to the student’s allergy
Yes
No
Other ____________________________________________________________________________________________
Field Trip Procedures— Students EpiPen / Auvi-Q will be available during school hours for any off campus activities.
Staff members on trip will be trained regarding EpiPen / Auvi-Q use and student health care plan (plan must be taken).
Other (specify): _____________________________________________________________________________________
Bus—Transportation should be alerted to student’s allergy
Yes
No
This student carries EpiPen / Auvi-Q on the bus:
Yes
No
EpiPen / Auvi-Q can be found in:
Backpack
On person
Student will sit at front of the bus:
Yes
No
Other (specify): ____________________________________________________________________________________
EMERGENCY CONTACTS
1.
Relationship:
Day Phone:
Cell Phone:
2.
Relationship;
Day Phone:
Cell Phone:
3.
Relationship:
Day Phone:
Cell Phone:
4.
Relationship:
Day Phone:
Cell Phone:
I approve this Severe Allergic Reaction Care Plan for my child.
I request this medication to be given as ordered by the Health Care Provider.
I give consent to share information about my child’s severe allergic reaction with the district nurse, health assistant, teachers,
principal, office staff, guidance, bus driver/transportation, cafeteria workers, playground staff, and emergency staff on a “need to know basis”.
I give Health Services Staff permission to communicate with the medical office about this care plan / medication. I understand the
medication(s) will not necessarily be given by the district nurse, but may be given by the health assistant or designated trained staff.
Parent/guardian must provide medication/equipment required to administer medication or provide special medical care.
All medication supplied must come in its original pharmacy-labeled container; and the container specifies the student’s name, name of prescriber, the
name of medication, the dose, the effective date, and the directions for administration.
(Grades 7—12) I request and authorize my child to carry and/or self-administer their medication.
Yes
No
This permission to possess and self-administer an EpiPen / Auvi-Q may be revoked by the principal/district nurse if it is determined that your child is not
safely and effectively able to self-administer.
Any changes in medication require a new written authorization and corresponding change in the prescription label.
I understand that the medication maintained in the health room is not available after school hours, and that I need to provide additional rescue
medications for my child when involved in sports/activities after school hours.
Parent/Guardian Signature ___________________________________________________________________ Date _________________________
District Nurse Signature ______________________________________________________________________ Date Reviewed _________________
Fax Numbers:
Big Bend 262-662-1309
Clarendon 262-363-6289
Eagleville 262-594-5495
Prairie View 262-392-6312
Rolling Hills 262-363-6343
Section 262-363-6341
Park View 262-363-6320
Mukwonago High 262-363-6239
District Nurse Phone: 262-363-6292 x27515 Fax: 262-363-6320
Page 2 of 2
Revised 05/26/2015 by LAH
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical