Form Doh 662-097 - Optometrist License Application Packet Page 25
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27Optometry Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
Optometry Certification for Administration of Epinephrine
by Injection for Treatment of Anaphylactic Shock
Applicant Name: ______________________________________________________________
F Certification For Administration Of Epinephrine By Injection For Treatment Of
Anaphylactic Shock
A minimum of four hours of didactic and supervised clinical instruction as established in
WAC 246-851-600
is required to administer epinephrine by injection for the treatment of
anaphylactic shock in the scope of optometric practice. Education must be completed after
May 1, 2004.
I certify the applicant has received a minimum of 4 hours of didactic and supervised clinical
WAC
246-851-600.
instruction as established in
Name of Accredited Institution______________________________________
Date Education Completed ________________________________________
School Seal
Signature______________________________________________________
WAC 246-851-600 Certification required for
B. Ocular urgencies:
administration of epinephrine by injection for
i. Thermal burns-direct and
treatment of anaphylactic shock.
photosensitivity-based ultraviolet burn;
1. To qualify for certification to administer
ii. Electrical injury;
epinephrine by injection for anaphylactic
iii. Cryo-injury and frostbite;
shock, licensed optometrists must provide
iv. Insect stings and bites;
documentation he or she:
v. Punctures, perforations, and
A. Are certified under RCW 18.53.010 (2)
lacerations;
(b) to use or prescribe topical drugs for
C. General urgencies and emergencies:
diagnostic and therapeutic purposes.
i. Anaphylaxis;
B. Have successfully completed a minimum
ii. Hypoglycemic crisis;
of four hours of didactic and supervised
iii. Narcotic overdose.
clinical instruction from an institution
3. The supervised clinical instruction must include
of higher learning, accredited by those
the following subject areas:
agencies recognized by the United States
A. Instrumentation;
Office of Education or the Council on
B. Informed consent;
Postsecondary Accreditation to qualify
C. Preparation (patient and equipment);
for certification by the optometry board to
D. All routes of injections.
administer epinephrine by injection.
4. With the exception of the administration of
2. The didactic instruction must include the
epinephrine by injection for treatment of
following subject area:
anaphylactic shock, no injections or infusions
A. Review of urgencies, emergencies and
may be administered by an optometrist.
emergency-use agents;
DOH 662-096 April 2017
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