Form Ss Se 64 – Fill Out and Use This PDF

EPINEPHRINE AUTHORIZATION

PLEASE READ INFORMATION AND PROCEDURES ON REVERSE SIDE

PART I PARENT OR GUARDIAN TO COMPLETE

I hereby authorize Fairfax County Public Schools (FCPS), Fairfax County Health Department (FCHD), and School Age Child Care (SACC) personnel to administer epinephrine injection(s) as directed by the physician (part II). I agree to release, indemnify, and hold harmless FCPS, FCHD, and SACC and any of their officers, staff members, or agents from lawsuits, claims, expenses, demands, or actions, etc., against them for administering the injection, provided they follow the physician's order (part II.) I am aware that the injection may be administered by a specifically trained nonhealth professional. I have read the procedures outlined on the back of this form and assume responsibility as required.

I understand that emergency medical services (EMS) will always be called when epinephrine is given, whether or not the student manifests any symptoms of anaphylaxis.

Student Name	(Last, First, Middle)
Date of Birth	School Name	School Year	Grade

No School Board employee, public health nurse, or school health aide shall administer medication or treatment, as an exception under School Board policy, unless all the required clearances have been personally reviewed by the principal or his or her designee.

Parent or Guardian Signature	Daytime Telephone	Date
PART II PHYSICIAN TO COMPLETE

Emergency injections are usually administered in FCPS or SACC by nonhealth professionals. These persons are trained by the school public health nurse to administer the injection. For this reason, only premeasured doses of epinephrine may be given. It should be noted that these staff members are not trained observers. They cannot observe for the development of symptoms before administering the injection.

The following injection will be given immediately after report of exposure to

				Indicate specific allergen(s)
Route of exposure:	Ingestion	Skin contact	Inhalation	Insect sting or bite

Check the appropriate boxes:

Give the premeasured dose of 0.3mg epinephrine 1:1000 aqueous solution (0.3cc) by autoinjection.

Repeat dose in 15 minutes if EMS has not arrived. (Two premeasured doses will be needed in school.)

Give the premeasured dose of 0.15mg epinephrine 1:2000 aqueous solution (0.3cc) by autoinjection.

Repeat dose in 15 minutes if EMS has not arrived. (Two premeasured doses will be needed in school.)

Check the appropriate box:

I believe that this student has received adequate information on how and when to use epinephrine.

The student is to carry an epinephrine autoinjector during school hours with the principal's knowledge. The student can use the epinephrine autoinjector

properly in an emergency. One additional dose, to be used as backup, should be kept in health room or other school location.

The epinephrine autoinjector will be kept in the school health room or following school-approved location:

.

Effective date:

Current school year

From

To

Physician Name (Print or Type)

Physician Signature

Telephone or Fax

Date

Parent or Guardian Name (Print or Type)

Parent or Guardian Signature

Telephone

Date

(Required if student carries epinephrine)

Student Signature

Date

(Required if student carries epinephrine)

PART III

PRINCIPAL OR PRINCIPAL DESIGNEE TO COMPLETE

Check √ as appropriate:

Principal or Principal Designee Signature

Date

Information from the Fairfax County Public Schools student scholastic record is released on the condition that the recipient agrees not to permit any other party to have access to such information without the written consent of the parent, guardian, or eligible student.

SS/SE-64 10/11 Distribution: Original-School, Copy-Parent or Guardian

PARENT INFORMATION ABOUT EPINEPHRINE PROCEDURES

1.Epinephrine may be given in school, during school-sponsored activities, or at SACC only with both physician and parent or guardian-signed authorization.

2.This form must be on file in the health room or in an other approved location. The parent or guardian is responsible for obtaining the physician's statement in part II. For a student who attends SACC, a copy of the medication form must be on file with SACC.

3.A new form must be submitted to the school each school year and whenever there is a change in the dosage or a change in the conditions under which epinephrine is to be injected.

4.A physician may use office stationery or a prescription pad in lieu of completing part II. Information necessary includes:

-Name of student

-Specific allergen(s) for which epinephrine is being prescribed

-Route of exposure (e.g., ingestion, skin contact, inhalation, or insect sting or bite)

-Brand name of medication

-Amount of premeasured epinephrine

-Time for repeated dose if deemed necessary

-Duration of medication order and effective dates

-Physician signature

-Date

5.Only premeasured doses of epinephrine may be given by FCPS, FCHD, and SACC staff members.

6.Medication must be properly labeled by a pharmacist. If a physician's orders include a repeat of the epinephrine injection, then the parent or guardian must supply the school with two epinephrine autoinjectors. For a student who carries his or her own epinephrine autoinjector, the parent must supply the school with a back up that is stored in the health room or other approved location. Expiration date must be clearly indicated on the pharmacy label or autoinjector. The parent must provide a replacement epinephrine autoinjector when notified that the current autoinjector has expired or has been administered.

7.Epinephrine must be hand-delivered to the school health room by the parent or guardian unless approved for the student to carry during school and SACC hours.

8.Unless the student has been authorized to carry epinephrine, the parent or guardian is to collect any unused epinephrine within one week after the end of expiration of the order or on the last day of school. Epinephrine not claimed within that period shall be destroyed.

SS/SE-64 10/11

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