Allergy Anaphylaxis Action Plan - 2015 Page 2
Download a blank fillable Allergy Anaphylaxis Action Plan - 2015 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Allergy Anaphylaxis Action Plan - 2015 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
A
/A
C
P
LLERGY
NAPHYLAXIS
ARE
LAN
Side 2: To Be Completed by Parent/Guardian, Student and School
Allergy/Anaphylaxis Action Plan (continued)
Student Name _________________________________________
Parent/Guardian AUTHORIZATIONS
I want this allergy plan implemented for my child; I want my child to carry an auto-injector and I agree to release
the school district and school personnel from all claims of liability if my child suffers any adverse reactions from self-
administration of an auto-injector.
I want this plan implemented for my child and I do not want my child to self-administer epinephrine.
I request that school staff be trained in to give emergency medications to my child in the absence of the nurse.
Parent is responsible for auto injectors for before and after school activities separate from the school day supply.
I understand that submission of this form may require the nurse to contact and receive additional information
from the health care provider regarding the allergic condition(s) and the prescribed medication.
Parent/Guardian Signature: ______________________________Phone:___________________ Date: _______________
E
C
Name
Home #
Work #
Cell #
MERGENCY
ONTACTS
Parent/Guardian
Parent/Guardian
Other:
Other:
Student Agreement:
I have been trained in the use of my auto-injector and allergy medication and understand the signs and symptoms for
which they are given;
I agree to carry my auto-injector with me at all times;
I will notify a responsible adult (teacher, nurse, coach, noon duty, etc.) IMMEDIATELY when my auto-injector
(epinephrine) is used;
I will not share my medication with other students or leave my auto-injector unattended;
I will not use my allergy medications for any other use than what it is prescribed for.
Student Signature: ____________________________________________
Date ____________________
Approved by Nurse/Principal Signature: ____________________________________
Date ____________________
PREVENTION: Avoidance of allergen is crucial to prevent anaphylaxis.
Indicates activity completed by school staff
Critical components to prevent life threatening reactions:
Encourage the use of Medic-alert bracelets
Notify nurse, teacher(s), front office and kitchen staff of known allergies
Use non-latex gloves and eliminate powdered latex gloves in schools
Ask parents to provide non-latex personal supplies for latex allergic students
Post “Latex Reduced Environment” sign at entrance of building
Encourage a No-Peanut Zone in the school cafeteria
Other:
STAFF MEMBERS TRAINED
Name
Title
Location/Room #
Trained By (RN only)
Anchorage School District
Nursing & Health Services; Adapted from the Asthma & Allergy Foundation of America, Alaska Chapter
Page 2 of 2
NUR # 0502
Rev 10/2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical