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JHCD-R

ALEXANDRIA CITY PUBLIC SCHOOLS

AUTHORIZATION TO ADMINISTER EPINEPHRINE AUTOINJECTOR FOR

THE MANAGEMENT OF ACUTE EMERGENCY ALLERGIC REACTIONS

Name of student: ______________________________________________ Grade: __________

School Year: ______________ Name of School: ____________________________________

Birth Date: ____________________

PART I: TO BE COMPLETED BY PARENT/GUARDIAN:

I will supply medication to the school nurse and request that this medication be available in the school as

prescribed by my student’s physician. I agree to release, indemnify, and hold harmless Alexandria City

Public Schools, their staff and agents from lawsuit, claim demand or action related to the use of this

medication.

My child IS ______ IS NOT______ capable of self-administration of the epinephrine autoinjector

medication.

I DO _____ DO NOT ____ want my child to carry the epinephrine autoinjector medication during the

school day.

The school nurse will release the epinephrine autoinector medication to the trained ACPS staff member

accompanying my child on every field trip during the current school year unless I request otherwise.

Before allowing the student to carry an epinephrine autoinjector in school, the school nurse will review

proper use with the student. The school nurse must sign that the student demonstrates proper knowledge

before the student will be allowed to carry the epinephrine autoinjector medication.

Parent Signature: ________________________________ Printed Name: __________________________

Contact Numbers: (H) __________________ (W) ______________________(C) ____________________

PART II: TO BE COMPLETED BY PHYSICIAN/LICENSED PRESCRIBER:

Name of medication: ___________________________________ (EPINEPHRINE AUTO INJECTOR)

Reason for medication: Management of acute allergic reaction to:

_____ a. stinging insects (bees, wasps, hornets, yellow jackets)

_____ b. ingestion of ______________________________________________________

_____ c. other ____________________________________________________________

Medication to be given:

_____ a. immediately after insect bite

_____ b. immediately after ingestion of _______________________________________

_____ c. other ___________________________________________________________

Route of administration: Intramuscularly into anterolateral aspect of thigh

Dosage of medication:

_____ Epinephrine Autoinjector 0.15mg

_____ Epinephrine Autoinjector 0.30mg

Possible side effects: _____________________________________________________________________

Physician/Licensed Prescriber’s Name: _____________________________________________________

(Signature)

(Printed/Stamped)

Physician/Licensed Prescriber’s contact number: __________________________ Date: _____________

PART III: TO BE COMPLETED BY THE SCHOOL NURSE:

Check as appropriate:

_____ Part I and II listed above completed with all information

_____ Medication is properly labeled

_____ Medication label and dosage match physician’s order

_____ I have reviewed the proper use of the Epi-Pen with the student and I

AGREE _____DISAGREE _____that the student should carry it during school hours.

Medication expiration date ______________

Nurse: (Signature): ______________________ (Printed/Stamped): _______________ Date: ________

Rev. 4/08

Form Jhcd-R - Authorization To Administer Epinephrine Autoinjector For The Management Of Acute Emergency Allergic Reactions - Alexandria City Public Schools

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