Cchs.k12.pa.us

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NO. 209.1 ATTACHMENT 1
CENTRAL CAMBRIA SCHOOL DISTRICT
Emergency Health Care Plan and Medication Orders for Life Threatening Allergies
Student Name: _______________________________________________________Date of Birth: _____________________School Year: __________________
School: _____________________________________________________________ Grade: _____________ Unit Teacher: ______________________________
Allergy to: _____________________________________________________________________________________ Asthmatic:  YES  NO
STEP 1: TREATMENT – To be completed by Physician
Symptoms:
Give Checked Medication (to be determined by
physician)
If exposure to an allergen occurs, but no symptoms ~Mouth Itching, tingling, or swelling of lips, tongue, mouth ~Skin Hives, itchy rash, swelling of the face or extremities ~Gut Nausea, abdominal cramps, vomiting, diarrhea ~Throat* Tightening of throat, hoarseness, hacking cough ~Lungs* Shortness of breath, repetitive coughing, wheezing ~Heart* Weak or thread pulse, low blood pressure, fainting, pale, blueness ~If reaction is progressing (several of the above areas affected), give: *Potentially life-threatening. The severity of symptoms can quickly change.

DOSAGE:
Epinephrine – Inject intramuscularly:  Epi-Pen 0.3 mg.  Epi-Pen Jr. 0.15 mg.
Antihistamine – give (medication/dose/route):  Benadryl __________mg.
Repeat Epi-Pen  YES  NO in 15 minutes if squad has not arrived – 2 kits will be needed in school.
STEP 2: EMERGENCY CALLS – To be completed by Parent/Guardian
1. Call 911 for Rescue Squad and ask for Advanced Life Support – state that an allergic reaction has been treated. 2. Call: Mother: Home: _________________________________ Work: __________________________________ Cell: ____________________________ Father: Home: _________________________________ Work: __________________________________ Cell: ____________________________ First: Name: ____________________________________ Relationship: _____________________________ Phone #: ________________________ Second: Name: __________________________________ Relationship: _____________________________ Phone #: ________________________ 3. Physician: _____________________________________________________________________________________ Phone #: _______________________ 4. Preferred Hospital: _______________________________________________________________________________ Phone #: _______________________ Page 2 of 2
SELF-ADMINISTRATION
I understand and agree that my child/patient requires the administration of epinephrine or a unit dose of Benadryl in conjunction with epinephrine when exposed
to a specific allergen and he/she is capable of self-administration of the medication.  YES  NO

DESIGNEES
I understand that the school nurse, when available, is responsible for emergency care to my child/patient. In the absence of the school nurse, the nurse can
designate and train another staff member to administer one or two Epi-Pens.  YES  NO Benadryl cannot be given by any designee.
CARRYING MEDICATION
I understand that on a trip, my child/patient may carry their own Epi-Pens and Benadryl.  YES  NO

BEFORE AND AFTER SCHOL PROGRAM
This Emergency Plan and Medication Order may be used in the Before and/or After School Programs.  YES  NO  N/A
I hereby acknowledge that the Central Cambria School District, its agents and employees shall incur no liability as a result of any injury arising from
the administration of a pre-filled, single dose auto-injector mechanism containing epinephrine to my child, and agree to indemnify and hold harmless
the District, its employees, and its agents against any claims arising out of the administration of a pre-filled, single dose, auto-injector mechanism
containing epinephrine.
First Parent/Guardian (circle one) Signature: ________________________________________________________ Date: ___________________________
Second Parent/Guardian (circle one) Signature: ______________________________________________________ Date: __________________________
School Nurse’s Signature: _________________________________________________________________________ Date: __________________________
Physician’s Signature AND STAMP: ________________________________________________________________ Date: __________________________

Source: http://www.cchs.k12.pa.us/Documents/Emergency_HCP_and_Med_Orders_for_Life_Threatening_Allergies_Attachment_1_Edit_version_PDF.pdf