SAMPLE
District Letterhead
Anaphylaxis Treatment Annual Notification to Parents
(LEAs may develop an annual notice to parents on anaphylaxis treatment)
California Education Code 49414 authorizes school districts to provide epinephrine auto-injectors to trained personnel to use to provide emergency medical aid to persons suffering from an anaphylactic reaction.
Anaphylaxis is a rapid, severe allergic response triggered by insect stings, foods, medications, latex materials, exercise, or in rare cases by unknown causes. This is a life-threatening allergic condition, requiring immediate treatment. Administering epinephrine to students during a medical emergency may help to insure the student’s health and safety at school. Therefore, the <District Name> has adopted a policy for standing orders or provide life-saving epinephrine to students who are in need of such treatment.
This policy states that a credentialed, licensed school nurse or trained, unlicensed school staff, under the direct or indirect supervision of the credentialed school nurse (or supervisor of health), may administer epinephrine in the form of an epinephrine auto-injector during a severe, life-threatening allergic reaction. The epinephrine auto-injector rapidly delivers a pre-measured, sterile, single dose of epinephrine by direct injection through the skin.
**If parents/guardians do not wish their child to receive this treatment, they must so indicate in writing within two weeks of the beginning of school.
**School districts may want to consider deleting the above sentence and not provide the parents with a ‘refusal for consent’ option. Ed Code 49400 states that school districts must‘give diligent care to the health…of pupils’ and Ed Code 49407 states that ‘no school district…in treating a child…shall be held liable for the reasonable treatment of the child without the consent of the parent…’ Parents can submit a written objection to care for anything other than ‘first aid’. This emergency treatment should be considered ‘first aid’ and since many staff members may be trained and anaphylaxis could occur anywhere, treatment should not be delayed until verification of approval is ascertained.**
SAMPLE
Parent/Guardian Statement of Consent for Use of Epinephrine Auto-injector
(This sample consent statement may be incorporated onto the student’s school emergency card.)
**This should only be used by Districts who want positive or negative permission for every student. Otherwise, Districts may choose to just provide Annual Notification with no permission requested**
In the event that my child experiences a severe, life threatening anaphylactic (allergic) reaction during school hours or during school related activities, I: (Check ONE)
Give my consent Do not give my consent
for trained/designated school staff to administer the epinephrine auto-injector emergency treatment, under the indirect supervision of the school nurse.
______
Parent/Legal Guardian Date
(Note: This treatment consent statement must be updated and signed each school year. Also, school staff must maintain a current list of pupils who do not have parent/guardian consent for the epinephrine auto-injector emergency treatment.)