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Action plan 2013.pdf

Student’s Name: _____________________________ D.O.B.___________________ ALLERGY TO: _______________________________________________________
A special table for lunch/snacks is requested.
Any of these symptoms can represent an allergic reaction:
1. Injectable Epinephrine (check one)
Mouth: itching and swelling of the lips, tongue or mouth
Skin: hives, swelling of the face or extremities
❑ Twinject™ 0.3mg ❑ Twinject™ 0.15mg Gut: nausea, abdominal pain, cramps, vomiting, diarrhea
2. Antihistamine
Throat: tightening of throat, hoarsess, hacking cough
Lungs: shortness of breath, repetitive cough, wheezing
Heart: weak or thready pulse,low blood pressure, fainting,
3. Other ___________________________
4. Call 911. State that an allergic reaction has
Other: _____________________________________________
occured and epinephrine has been given.
5. Call Emergency Contacts (see below)
1. Antihistamine
Symptoms: itchy rash or a few hives
❑ Benadryl ______________❑ Other _________________ 2. Call Emergency Contacts (see below)
Emergency Contacts:
1. Name/Relationship Phone Number(s) Phone Number(s)

a. _______________________________________ ________________________ _______________________b. _______________________________________ ________________________ _______________________c. _______________________________________ ________________________ _______________________ Even if parent/guardian cannot be reached, do not hesitate to medicate or call 911.
2. _________________________________________________________________________________________________
❑ The school may post this form in a visible location. ❑ If the patient presents to the emergency department, please monitor the patient for a biphasic reaction for at least ______ hours.
❑ Two doses of Epinephrine should be kept at school in case a repeat dose is needed.
❑ The student is capable and has been instructed in the proper method of self administering the medications named above and may carry the medicines during school hours.
______________________________ ________________________________ ______________________________ Physician/Provider Signature Parent Signature Principal Signature TRAINED STAFF MEMBERS
1. _______________________________________________________________________________ Room _______
2. _______________________________________________________________________________ Room _______
3. _______________________________________________________________________________ Room _______
Twinject® 0.3 mg and Twinject® 0.15 mg Directions Hold black tip near outer thigh (always apply to thigh). Remove caps labeled “1” and “2.” Place rounded tip against outer thigh, press down hard until needle penetrates. Hold for 10 seconds, then remove.
to 10. Remove the EpiPen® unit and massage the injection area for 10 syringe from barrel by holding blue collar at needle base. 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.


Microsoft word - oo3_reglement_2012_01_27-en.doc

OPEN CALL Designer Selection Procedure in Public Building Procurement Introduction A town hall, an administrative building, a post office, a swimming pool, a bus shelter, an electrical substation, a noise barrier, a bridge - the demand is there and the funds are waiting, but how do you find an architect or designer to come up with a suitable, sustainable design? It was for this ver

Microsoft word - policy 504.3.1-r.doc

Policy 504.3.1-R Administering Medications to Students For the purposes of this Regulation, the following definitions apply: Supervision of Medication When a school staff member "supervises" a student taking medication, he or she simply monitors the student taking the medication on their own, having been informed of the need by a note from the parent. Administration of Me

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