HENRY P. BECTON REGIONAL HIGH SCHOOL Phone: (201)-935-3007 Fax: (201)-935-5639 Epinephrine Auto-Injectior(Epipen)/ALLERGY MEDICATION MUST BE RENEWED EACH SCHOOL YEAR School Year: ____________ Student Name:_____________________________ DOB:___________Grade:____ TO BE COMPLETED BY A PHYSICIAN: PLEASE COMPLETE BOTH SIDES ****NOTE TO PHYSICIAN/PARENT:**** State law only permits a student to self-administer an epinephrine auto-injector (Epipen), or Benadryl simultaneously with an Epipen. An order of Benadryl first, then Epipen upon further symptoms requires a medical assessment, and therefore, that order is not permitted during school or school-sponsored activities unless it is performed by a nurse, physician, or a parent who is present. A delegate or the student may not observe and then administer Benadryl.
The above student is allergic to:______________________________________________ To control reactions the following medications are prescribed: __________Epipen Sr. __________Epipen Jr. Other:__________________________________________________________________ Name of Medication and Specific Dosage (may not be self-administered unless Benadryl prescribed simultaneously with Epipen) The epinephrine auto-injector is to be given:
___________Immediately (do not wait for symptoms) ___________After the following symptoms occur (please check those that pertain): _____Apprehension _____Itching/Skin Burning _____Sneezing/Coughing _____Wheezing/Shortness of Breath _____Hives _____Cyanosis _____Difficulty Breathing _____Loss of Consciousness/Drowsiness _____Loss of Color _____Flushing Other:_____________________________ IfBenadryl is prescribed above with an Epipen order, it is to be given: _________Simultaneously with Epipen (No observation for symptoms to occur before Epipen)
_________Before an Epipen, as the first medication given (please circle one)before // after any of above symptoms occur. After giving Benadryl, if symptoms do not improve within_______ minutes, administer the Epipen. (this order is permitted only to school nurse, physician, or parent) *********PLEASE COMPLETE BOTH SIDES********* Epinephrine Auto-Injector (Epipen) will be kept:
___________In the possession of student to SELF-ADMINISTER (student is capable of and has been instructed in the proper administration of the Epipen) ___________Stored in a secure unlocked location to be administered by nurse, or an assigned delegate, if permitted) ***The State recommends that a back-up/spare epinephrine auto-injector be supplied by the student’s parent/guardian. Licensed Provider: Please include this in your orders ***
Benadryl may ONLY be self-administered when the physician’s order states that the prescribed Benadryl dose is to be given SIMULTANEOUSLY with an Epipen, without observation for symptoms. Student is permitted in school to carry only the prescribed dose of Benadryl with an Epipen, when ordered to be given simultaneously with the Benadryl. A student MAY NOT administer Benadryl, observe himself, then self- administer Benadryl if needed. By law, only a nurse may follow such an order at a school- sponsored activity.
SCHOOL-SPONSORED EVENTS and/or VARSITY ATHLETIC PARTICIPATION (Please check): For Health Providers who have designated the school nurse to medicate during school hours: Orders for field trips, varsity athletics, or intramurals may differ from regular school hour orders. If a school nurse is ordered to give the medication in school, please have the provider check below whether the student may self-administer only the orders in accordance to bold lettering above during school-sponsored events and athletic sports. Student __________MAY _______________ MAY NOT self-administer the above medication(s) on school-sponsored events or during varsity athletics. State law states that a school nurse shall assign a delegate, who volunteers and is properly trained, to administer a student’s auto-injector epinephrine if student is incapable, should the nurse or parent be unavailable. Physicians, please discuss this with your patient.
____________________________________ _____________________________ Physician’s Name Physician’s Signature ______________________ Physician’s Stamp: Date
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