Parent Consent And Authorized Healthcare Provider Authorization For Management Of Anaphylaxis At School And School-Sponsored Events

Parent Consent and Authorized Healthcare Provider Authorization for

Management of Anaphylaxis at School and School-sponsored Events

Pupil:

DOB:

Date:

School:

Teacher/Rm:

Grade:

Medical office:

Patient Identification #:

6. Administer epinephrine when:

1. Allergens or factors causing anaphylactic reaction:

Pupil has severe symptoms of anaphylaxis:

Pupil has definite exposure to allergen;

2. Pupil’s most common signs and symptoms:

No immediate symptoms noted.

Pupil has any symptoms after suspected exposure

to allergen

Administer 2

dose

min. after 1

dose if

3. Pupil’s typical reaction time after allergen exposure:

symptoms persist or recur

7. Medications administered after epinephrine

4. Date of last anaphylactic reaction:

None

5. Medication—Epinephrine auto-injector:

Antihistamine:

EpiPen 0.3mg

EpiPen Jr. 0.15 mg

Dose:

Route:

Twinject 0.3mg

Twinject 0.15mg

Other medication:

Other:

mg.

Dose:

Route:

: 911 emergency services will be called and pupil

OTE

transported to emergency room if anaphylactic

reaction occurs and is treated in school setting.

Additional medical orders:

Authorized Healthcare Provider Authorization for Management of Anaphylaxis In School Setting

My signature below provides authorization for the above written orders. I understand that all procedures will be

implemented in accordance with state laws and regulations. I understand that specialized physical healthcare services may

be performed by unlicensed designated school personnel under the training and supervision provided by the school nurse.

This authorization is for a maximum of one year. If changes are indicated, I will provide new written authorization.

Authorizations may be faxed.

*Authorized Healthcare Provider Name ________________________Signature ______________________________

Date________ Phone ______________ Address _______________________City ___________________Zip _______

*Nurse Practitioner, Nurse Midwife, Physician Assistant: Furnishing Number _______________________________

Supervising Physician Name ______________________ Address _________________________ Phone __________

 I request that the school nurse provide me with a copy of the completed Individualized Healthcare Plan (IHP).

Parent Consent for Authorization and Management of Anaphylaxis in School Setting

I (we) the undersigned, the parent(s)/guardian(s) of the above named pupil, request that the specialized physical healthcare

service, anaphylaxis treatment, be administered to my (our) child in accordance with state laws and regulations. I (we) will:

1. provide the necessary supplies and equipment;

2. notify the school nurse if there is a change in child’s health status or attending authorized healthcare provider; and

3. notify the school nurse immediately and provide new written consent/authorization for any changes in the above

authorization.

I (we) give consent for the school nurse to communicate with the authorized healthcare provider when necessary.

I (we) understand that I (we) will be provided a copy of my child’s completed Individualized Healthcare Plan (IHP).

Parent(s)/Guardian(s) Signature ___________________________________________________Date _____________

___________________________________________________ Date_____________

Reviewed by school nurse (signature)

Date

School nurse has informed principal about SPHCS being provided for this pupil.

Form B, Anaphylaxis; Section 3, The Green Book: Guidelines for Specialized Physical Healthcare Procedures in School Settings (4/11)

Parent Consent And Authorized Healthcare Provider Authorization For Management Of Anaphylaxis At School And School-Sponsored Events - Form

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