EPI-PEN AUTHORIZATION

Fredericksburg Cooperative Preschool

PLEASE READ INFORMATION AND PROCEDURES (Attached)

PART 1: PARENT OR GUARDIAN TO COMPLETE
I hereby authorize Fredericksburg Cooperative Preschool personnel to administer
___epinephrine injection
as directed by the physician (Part II). I agree to release, indemnify,and hold harmless Fredericksburg Cooperative Preschool and any of their officers, staff members, or agents from lawsuit, claim, expense, demand, or action
against them for administering the injection, provided they follow the physician order as written in Part II below. I am aware that the injection will be administeredby a specifically trained non-health professional. I have read the procedures accompanying this form and assume responsibility as required.
Student Name: (Last, First, Middle) / Date of Birth:
______
Parent or Guardian Signature Daytime Phone # Date
PART II: PHYSICIAN TO COMPLETE
Emergency injectionsare administered by non-health professionals. These persons are MAT trained and certified 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 trainedobservers. They cannot observe for the development of symptoms before administering the injection.
Emergency personnel will be called immediately upon administration of this medication.
The following injection will be given immediately after report of exposure to ______Indicate specific
allergen and type of exposure (e.g., ingestion, skin contact, or inhalation).
Check as appropriate:
Epi-pen
□ Give the premeasured dose by auto injection.
□ Repeat dose in 15 minutes if rescue squad has not arrived. (Two kits will be needed in school.)
Epi-pen Jr.
□ Give the premeasured does of 0.15 mg epinephrine 1:2000 aqueous solution (0.3cc).
□ Repeat dose in 15 minutes if rescue squad has not arrived. (Two kits will be needed in school.)
Medication kept in the school will be stored in a secure area accessible only to authorized personnel.
NOTE: Medication expiration date must be clearly indicated
______
Physician Name (Print or Type) Physician Signature Telephone/Fax Date
Effective Date: From ______(date) or _____ beginning of school year to ______(date) or end of school year
PART III DIRECTOR OR DESIGNEE TO COMPLETE
□ Parts I and II above are completed including signatures. (It is acceptable if all items of information in Part II are written on physician stationeryor a prescription pad.)
□ Medication is appropriately labeled.
______
Director or Director Designee Signature Date

Last revised: November 2010

PARENT INFORMATION ABOUT EPINEPHRINE PROCEDURES

1.Epinephrine may be given in school, during school sponsored activities, only with a signed physician order, parent/guardian and Director/designee signatures.

2.The signed physician order must be on file in the student’s records at the school. The parent/guardian is responsible for obtaining the physician order.

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

4.A physician must complete the Medication Request Form. For each emergency medication Necessary information includes:

Student’s name

allergen for which epinephrine is being prescribed

type of exposure (e.g.: ingestion, skin contact or inhalation)

brand name

amount of premeasured epinephrine

time for repeated dose if deemed necessary

physician signature, name, address, telephone number

date

  1. Medication must be properly labeled by a pharmacist. If physician orders include a repeat of Epi-pen injection, the parent must supply the school with two Epi-pens. The expiration date must be clearly indicated. Pharmacy label must be on the unopened medication with the following information:

Student’s name

allergen for which epinephrine is being prescribed

type of exposure (e.g.: ingestion, skin contact or inhalation)

brand name

amount of premeasured epinephrine

time for repeated dose if deemed necessary

physician name, address, telephone number

pharmacy name and telephone #

  • date prescription fulfilled
  • expiration date

6. Over the counter emergency medication must be delivered to the school in an unopened original package with the student’s name clearly marked on the package.

7.The parent/guardian must hand deliver the medication to the school personnel.

  1. Medication kept in the school will be stored in a secure area accessible only to authorized personnel.

9. A parent/guardian is to collect any unused medication within one week of expiration of the physician order. Unclaimed medication will be destroyed.

  1. In compliance with MAT training andVirginia Department of Social Services licensing guidelines, this form is valid for only 6 months unless otherwise noted by the Physician. A new, signed copy must be resubmitted every 6 months when the order is not submitted for the entire year.
  1. Fredericksburg Cooperative Preschool ONLY administers emergency medications. Any medications required for emergency use only to be used with the Epi-pen must be provided and clearly marked and the physician must designate dosage and administration dosage in accordance with the guidelines above. Each medication required for emergency use requires a separate medication request form.

PART II PHYSICIAN TO COMPLETE

O COMPLETELast revised: November 2010