also emphasize that if in doubt as to the size or weight of a child, the higher dose should be administered. Train, practice and evaluate impacted staff in activating the Anaphylaxis Response Protocol in case of a food allergy emergency Immediately alerting 911 emergency medical services Train, practice and evaluate communications with parents AFTER alerting 911 Training in school specific emergency logistical information Document training and evaluation of training Statement of Response Protocol and Follow-up Care School Specific Response Protocol has developed a school specific response protocol for the emergency administration of epinephrine which includes the following minimum requirements: Injector specific training for impacted staff members. The distribution of clear step-by-step auto-injector specific instructions, and the posting of these instructions near the general use epinephrine injector. (See Example school’s Appendix D.) The training of all staff members and impacted staff members as described in the previous section, including training in the Anaphylaxis Response Protocol and school’s specific emergency logistical information. (See Appendix C.) Alongside the use epinephrine injector, the school will also store a school’s general clearly labeled pre-measured 135cm. string or pre-cut measuring tape to assist in the determination of dosage, and latex-free gloves. has ensured that all impacted staff has been trained in the above protocol and have demonstrated competency in carrying out the emergency responses. Follow-up Protocol If at any time epinephrine is given at school, the Report of an Anaphylactic Reaction/Epinephrine Administration Form (Appendix E) must to be completed and copies given to the school administration, school nurse/other licensed health care practitioner, physician/licensed provider, and Archdiocese Office of Risk Management. In addition, the follow-up protocol provides that the school nurse or other licensed health care practitioner must follow up with the student and his or her family to obtain the necessary forms and medications at school for a child with what is now defined as a known risk of severe allergic reaction. Signature____________________________________ Physician/Licensed Prescriber’s
also emphasize that if in doubt as to the size or weight of a child, the higher dose should be administered. Train, practice and evaluate impacted staff in activating the Anaphylaxis Response Protocol in case of a food allergy emergency Immediately alerting 911 emergency medical services Train, practice and evaluate communications with parents AFTER alerting 911 Training in school specific emergency logistical information Document training and evaluation of training Statement of Response Protocol and Follow-up Care School Specific Response Protocol has developed a school specific response protocol for the emergency administration of epinephrine which includes the following minimum requirements: Injector specific training for impacted staff members. The distribution of clear step-by-step auto-injector specific instructions, and the posting of these instructions near the school’s general use epinephrine injector. (See Example Appendix D.) The training of all staff members and impacted staff members as described in the previous section, including training in the school’s Anaphylaxis Response Protocol and specific emergency logistical information. (See Appendix C.) Alongside the school’s general use epinephrine injector, the school will also store a clearly labeled pre-measured 135cm. string or pre-cut measuring tape to assist in the determination of dosage, and latex-free gloves. has ensured that all impacted staff has been trained in the above protocol and have demonstrated competency in carrying out the emergency responses. Follow-up Protocol If at any time epinephrine is given at school, the Report of an Anaphylactic Reaction/Epinephrine Administration Form (Appendix E) must to be completed and copies given to the school administration, school nurse/other licensed health care practitioner, physician/licensed provider, and Archdiocese Office of Risk Management. In addition, the follow-up protocol provides that the school nurse or other licensed health care practitioner must follow up with the student and his or her family to obtain the necessary forms and medications at school for a child with what is now defined as a known risk of severe allergic reaction. Physician/Licensed Prescriber’s Signature____________________________________
General-Use-Epinephrine-Program-2016-2017-Fillable-Form-4.docx