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school year unless renewed and initialed by provider. EMERGENCY ALLERGY PLAN: FOOD OR INSECT
AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINE BY SCHOOL/DAYCARE/CAMP PERSONNEL Connecticut State Law and Regulations 10‐212(a) require a written medication order of an authorized prescriber, (physician, dentist, advanced practice registered nurse or physician's assistant) and parent/guardian written authorization, for the nurse, or in the absence of the nurse, a designated principal or teacher to administer medication. Medications must be in the original properly labeled container and dispensed by a physician/pharmacist. Student Name _______________________________________________________DOB___________________________ History of Asthma __Yes __No Home Phone_________________________________Work Phone___________________________Cell_____________________________Grade________________ Health Care Provider Name(s)___________________________________________________________ Phone___________________________________________  Notify provider if treatment received
 Administer bronchodilator after Epi‐Pen if student has a history of asthma
Potential Life-Threatening
 Call 911 for ED evaluation if Epi‐Pen administered
Allergen(s)

ANAPHYLAXIS MANAGEMENT
IF STUDENT INGESTS / IS STUNG OR IS THOUGHT TO HAVE BEEN EXPOSED TO THE FOLLOWING:
25mg 50mg Do not Administer Benadryl 2. Notify Parent of exposure/potential exposure
3. Observe student for symptoms of Anaphylaxis*
4. Administer Epi Pen IM for any symptoms of Anaphylaxis
Prescriber authorization to self‐administer Yes No 5. Call Emergency Services if Epinephrine administered (911) Other:_____________________________________________________________________ ORAL ALLERGY SYNDROME (OAS) MANAGEMENT
Known Oral Allergy
F STUDENT INGESTS OR IS THOUGHT TO HAVE BEEN EXPOSED TO THE FOLLOWING & SYMPTOMS
Syndrome Allergen(s)
ARE LIMITED TO THE LIPS, MOUTH, AND TONGUE:
50mg Do not Administer Benadryl Other:_____________________________________________________________________ 2. Observe student for progressing symptoms of Anaphylaxis*
3. Administer Epi Pen IM for any additional symptoms of Anaphylaxis Jr Adult
Prescriber authorization to self‐administer ___________________________________________________________________________ Date Renewed/Initials_____________ Health Care Provider Signature
Date Date Renewed/Initials_____________ ___________________________
Stamp or Printed Name
Parent/Guardian:
Parent/Guardian:
I have reviewed and agree with the above protocol. I authorize communication between the Authorization to self‐administer medication: prescribing health care provider and school necessary for the safe implementation of this treatment ______________________________________________________________________________________________ _______________________________________________ Parent/Guardian Signature Date
Parent/Guardian Signature Date
*Symptoms of LIFE‐THREATENING anaphylaxis:
Usually occurs within minutes, but may occur up to 2 hours after exposure Chest tightness, wheezing, cough, shortness of breath Difficulty swallowing, tightness in throat Dizziness, fainting, “feeling of impending doom”

Source: http://www.hopkins.edu/ftpimages/82/download/2013%20Authorization%20for%20Emergency%20Allergy.pdf