Epi-Pen Form

Student's Name*
Date of Birth*

MonthDayYear
Date
School Name
Grade
Teacher
Parent/Guardian Name
Phone Number*
Please enter a valid phone number.
Address
Emergency Contact (Name)
Emergency Contact (Phone Number)
Please enter a valid phone number.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Fax Number
Please enter a valid phone number.
Medical Diagnosis*
ie. Peanut allergy, Allergy to bee stings...
Choose One*

Student will carry/self admnister medicationSchool staff will store and administer medicationNo medication is required
Medication and/or medical supplies will be located at:*

OfficeTeacher's deskStudent's deskStudent's backpackLockerOther
The student should avoid the following anaphylaxis triggers in any form, including skin contact:*

PeanutsTree nutsMilkAll dairyEggsShellfishFishInsect StingsMedicationFood additivesOther
Please Specify (food additive)
Please Specify (Insect)
Please Specify (Medication)
The student's anaphylaxis symptoms are as follows and usually have a rapid onset:*

Change of voiceCold, clammy, sweaty skinCoughing or chokingDifficulty breathing or swallowingDizziness, confusionFainting or loss of consciousnessFeelings of apprehensionFeeling of throat "closing off"Flushed face or bodyHivesItchingSwelling (eye, lips, face, tongue)Shallow respirationsStomach cramps, diarrheaSweatingTingling sensation in the mouth, face or throatVomitingWeaknessWheezingOther
If school personnel recognizes the student is experiencing anaphylaxis symptoms, they must initiate the treatment as oulined below

The student's medication(s) must be administered as directed by their health car provider.911 MUST BE CALLED IMMEDIATELY!! The dispatcher should be informed that a child is having a life-threatening anaphylactic reaction.The parent/guardian and/or emergency contact and the school nurse should then be notified.CPR MUST BE ADMNISTERED IMMEDIATELY IF THE STUDENT STOPS BREATHING.
Additional Information
Check One Box:*

Student has a disability which requires a special meal or accommodation. (Refer to definitions on reverse sideof this form.) A licensed medical physician must sign this form.Student does not have a disability, but is requesting a special meal or accommodation due to foodintolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schoolsand agencies participating in federal nutrition programs may accommodate reasonable requests. A licensedmedical physician, physician’s assistant, registered nurse, nurse practitioner, or registered dietitian must signthis formThe student does not have a disability. A fluid milk substitution is being requested for the student. Schools andagencies participating in federal nutrition programs may choose to accommodate this request by providing aUSDA approved fluid milk substitute. A licensed medical physician, physician’s assistant, registered nurse,nurse practitioner, registered dietitian, parent, or guardian must sign this form.
State the disability or medical condition requiring a special meal, accommodation, or fluid milk substitute.*
ie. Dairy allergy, peanut allergy, Celiac disease...
If student has a disability, provide a brief description of the major life activity affected by the disability.*
ie. respiratory failure, confusion...
Diet prescription and/or accommodation: (Please describe in detail to ensure proper implementation.)*
ie. No dairy, No nuts...
Indicate Texture*

RegularChoppedGroundPureed
Foods to be Omitted
Foods to be Substituted
Any adaptive equipment needed:
Name of Medication*
Dosage*
Possible Side Effects*
- My child and I understand there may be serious consequences, including suspension/expulsion from school, for sharing any medications and/or supplies with other students or school staff.
- I certify that the epinephrine auto injector has been prescribed for him/her. I request that the student’s public school identify and train school personnel who volunteer to be trained in the administration of Epinephrine Auto Injector (EAI) medication in accordance with Utah Code 53A-11-603 and 26-
  42, HB 101, 2008 General Session. I authorize the administration of Epinephrine Auto Injector(EAI) medication in an emergency to the identified student in accordance with Utah Code 53A-11-603.
Parental Responsibilities:
- The parent or guardian is to furnish the Epinephrine Auto Injector(EAI) medication and bring to the school in the current original pharmacy container and pharmacy label with the child’s name, medication name, administration time, medication dosage, and healthcare provider’s name.
- The parent or guardian, or other designated adult will deliver to the school and replace the Epinephrine Auto Injector(EAI) medication within two weeks if the Epinephrine Auto Injector(EAI) single dose medication is given.
- If a student has a change in his/her prescription, the parent or guardian is responsible for providing the newly prescribed information and dosing information as described above to the school. The parent or guardian will complete an updated Epinephrine Auto Injector(EAI) Authorization Form before the designated staff can administer the updated Epinephrine Auto Injector(EAI) medication prescription.
- The parent or guardian will complete, sign and deliver an Epinephrine Auto
  Injector(EAI) Medication Form if the student is to possess Epinephrine Auto
  Injector(EAI) medication at all times. I give my permission for the school nurse or school designee to contact my child’s healthcare provider if
  clarification is needed to administer Epinephrine Auto Injector(EAI). I agree to meet the parental responsibilities listed above. I give my permission for school personnel to release personal or medical information about my child in a health-related emergency situation if necessary. I understand this
  completed and signed form authorizes designated school personnel to administer epinephrine in emergency situations consistent with Utah Law.
Name of parent/guardian that agree with the statement above*
Phone Number of parent/guardian that agree with the statement above*
Please enter a valid phone number.
Signature of parent/guardian that agree with the statement above*

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