Food Allergy Action Plan Form (Page 2 of 2) in pdf

Food Allergy Action Plan Form Page 2

TRAINED STAFF MEMBERS

1. ____________________________________________________

Room ________

2. ____________________________________________________

Room ________

3. ____________________________________________________

Room ________

EpiPen® and EpiPen® Jr. Directions

Twinject™ 0.3 mg and Twinject™ 0.15 mg

Directions

Pull off gray activation cap.

Hold black tip near outer thigh

Pull off green end cap, then red end cap.

(always apply to thigh).

Put gray cap against outer

thigh, press down firmly

until needle penetrates. Hold

for 10 seconds, then remove.

Swing and jab firmly into outer thigh

SECOND DOSE ADMINISTRATION:

until Auto-Injector mechanism

If symptoms don’t improve after

functions. Hold in place and count

10 minutes, administer second dose:

to 10. Remove the EpiPen® unit and

massage the injection area for 10

Unscrew gray cap and pull

seconds.

syringe from barrel by holding

blue collar at needle base.

Slide yellow or orange

collar off plunger.

Put needle into thigh through

skin, push plunger down

all the way, and remove.

Once EpiPen® or Twinject™ is used, call the Rescue Squad. Take the used unit with you to the

Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours.

For children with multiple food allergies, consider providing separate Action

Plans for different foods.

**Medication checklist adapted from the Authorization of Emergency Treatment form

developed by the Mount Sinai School of Medicine. Used with permission.

Food Allergy Action Plan Form Page 2