Annual Risk Management Checklist School Name: Date of Review: Who completed Name: this checklist? Position: Review to: Name Position Comments: General Information How many current students have been diagnosed as being at risk of anaphylaxis, and have been prescribed an Adrenaline Autoinjector? How many of these students carry their Adrenaline Autoinjector on their person? Have any students ever had an allergic reaction requiring medical intervention at Yes No school? If Yes, how many times? Have any students ever had an Anaphylactic Reaction at school? Yes No If Yes, how many students? If Yes, how many times Has a staff member been required to administer an Adrenaline Autoinjector to a Yes No student? If Yes, how many times? Was every incident in which a student suffered an anaphylactic reaction reported Yes No via the Incident Reporting and Information System (IRIS)? SECTION 1: Individual Anaphylaxis Management Plans Does every student who has been diagnosed as being at risk of anaphylaxis and Yes No prescribed an Adrenaline Autoinjector have an Individual Anaphylaxis Management Plan and ASCIA Action Plan completed and signed by a prescribed Medical Practitioner? Are all Individual Anaphylaxis Management Plans reviewed regularly with Parents Yes No (at least annually)?
Annual Risk Management Checklist School Name: Date of Review: Who completed this checklist? Name: Position: Review to: Name Position Comments: General Information How many current students have been diagnosed as being at risk of anaphylaxis, and have been prescribed an Adrenaline Autoinjector? How many of these students carry their Adrenaline Autoinjector on their person? Have any students ever had an allergic reaction requiring medical intervention at school? Yes No If Yes, how many times? Have any students ever had an Anaphylactic Reaction at school? Yes No If Yes, how many students? If Yes, how many times Has a staff member been required to administer an Adrenaline Autoinjector to a student? Yes No If Yes, how many times? Was every incident in which a student suffered an anaphylactic reaction reported via the Incident Reporting and Information System (IRIS)? Yes No SECTION 1: Individual Anaphylaxis Management Plans Does every student who has been diagnosed as being at risk of anaphylaxis and prescribed an Adrenaline Autoinjector have an Individual Anaphylaxis Management Plan and ASCIA Action Plan completed and signed by a prescribed Medical Practitioner? Yes No Are all Individual Anaphylaxis Management Plans reviewed regularly with Parents (at least annually)? Yes No
RiskChecklistTemplate.docx