Asthmatic ☐ YES ☐ NO
If a food allergen has been ingested, but no symptoms ☐Observe for symptoms ☐Epinephrine ☐Antihistamine ☐Albuterol Observe for Symptoms:
Number order of Medication
Itching, tingling or swelling of lips,
_ Epinephrine _ Antihistamine _ Albuterol
Hives, itchy rash, swel ing of the face or
_ Epinephrine _ Antihistamine _ Albuterol
Nausea, abdominal cramps, vomiting,
_ Epinephrine _ Antihistamine _ Albuterol
Tightening of throat, hoarseness, hacking
_ Epinephrine _ Antihistamine _ Albuterol
Shortness of breath, repetitive coughing,
_ Epinephrine _ Antihistamine _ Albuterol
Weak or thready pulse, low blood
_ Epinephrine _ Antihistamine _ Albuterol
pressure, fainting, pale, blueness
_ Epinephrine _ Antihistamine _ Albuterol
Epinephrine: Inject into thigh (circle one): EpiPen® EpiPen® Jr. Twinject® 0.3 mg Twinject® 0.15 mg Antihistamine: Give________________________________________________________________
Albuterol: Give________________________________________________________________
Other: Give______________________________________________________________________
✚ Administer rescue medication as prescribed above ✚ Stay with child ✚ Contact parents/guardian IF THIS HAPPENS
✜ Hard time breathing with:
GET EMERGENCY HELP
✜ Chest and neck pulled in with breathing ✜ Child is hunched over
✜ Child is struggling to breathe
✜ Trouble walking or talking ✜ Stops playing and can’t start activity again
✜ Lips and fingernails are gray or blue
Child’s Name: ALLERGY MEDICAL ACTION PLAN ADDITIONAL CONSIDERATIONS (to be completed by Health Care Provider)
Medications for Allergy For children requiring rescue medication, the medication is required to be at program site at al times while child is in care. For youth who self-medicate and carry their own medications, medication must be with the youth at al times. The options of storing “back up” rescue medications at program is available. Travel Procedures Rescue medications should accompany child during any off-site activities. · The child should remain with staff or parent/guardian during the entire field trip. □ Yes □ No · Staff members on trip must be trained regarding rescue medication use and this health care plan. This plan must accompany the child on the field trip. · Other (specify)_________________________________________________________________________ Self-Medication for Youth □ YES. Youth can self-medicate. I have instructed _______________________in the proper way to use his/her medication. It is my professional opinion that he/she SHOULD be allowed to carry and self administer his/her medication. Youth has been instructed not to share medications and should youth violate these restrictions the privilege of self medicating wil be revoked and the youth’s parents notified. Youth are required to notify staff when carrying medication.
□ NO. It is my professional opinion that _______________________SHOULD NOT carry or self administer his/her medication. Parental Permission/Consent Parent’s signature gives permission for child/youth personnel who have been trained in medication administration to administer prescribed medicine and to contact emergency medical services if necessary. I also understand my child must have required medication with him/her at all times when in attendance. Youth Statement of Understanding I have been instructed on the proper way to use my medication. I understand that I may not share medications and should I violate these restrictions, my privileges may be restricted or revoked, my parents wil be notified and further disciplinary action may be taken. I am also required to notify staff when carrying medication. Follow Up This Al ergy Medical Action Plan wil be updated/revised whenever medications or child’s health status changes. If there are no changes, the Al ergy Medical Plan wil be updated at least every 12 months. I agree with the plan outlined above.
Printed Name of Parent/Guardian
Printed Name of Youth (if applicable)
Stamp of Health Care Provider
Health Care Provider Signature
AIRWORTHINESS DIRECTIVE of Transportation Federal Aviation Administration We post ADs on the internet at www.faa.gov/aircraft/safety/alerts/ The following Airworthiness Directive issued by the Federal Aviation Administration in accordance with the provisions of Title 14 of the Code of Federal Regulations (14 CFR) part 39, applies to an aircraft model of which our records indica
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Asthmatic ☐ YES ☐ NO
If a food allergen has been ingested, but no symptoms ☐Observe for symptoms ☐Epinephrine ☐Antihistamine ☐Albuterol Observe for Symptoms:
Number order of Medication