Southington Public Schools

Food Allergy Individualized Health Care Plan

Student: ______DOB: ______Grade: ______Teacher: ______

Allergy: ______Home Phone: ______Plan effective from: ______to ______

Assessment
Date/Nurse / Functional Health
Concern / Student
Objective(s) / Interventions / Evaluation
Risk of anaphylactic reaction (life-threatening allergic response) related to the ingestion or inhalation of peanuts and/or tree nuts (protein component) or ______.
Risk of severe allergic reaction to the ingestion / inhalation or contact of: ______
Asthma History:
□ Yes □ No
Student has an
Emergency Care Plan (ECP) in accordance with MD orders and/ or Food Allergy Action Plan (F.A.A.P.) / ______will cooperate with staff 100% of the time by following school, classroom and IHCP rules in order to remain free of allergic reactions while in school especially improving the skills of food refusal and advocating for himself/herself when allergens may be present in the environment.
If ______suspects that he/she has ingested: ______, student will immediately notify staff who will implement the ECP according to the allergen-specific plan.
______will cooperate with staff members 100% of the time if they need to implement the ECP. / Parent/Legal Guardians will:
○ inform school nurse and teacher of food allergy.
○ provide a physician’s order and medication(s) for medical intervention:
○ inform school nurse of any changes in health status as relates to food allergy and
treatment.
○ educate student in safe choices and the self-management of his/her food allergies
appropriate for his/her age level.
○ provide emergency contact information.
○ meet with school nurse, administrator and teacher to develop a prevention plan.
○ work directly with before and after school programs, coaches and bus driver if
applicable.
Elementary level:
○ provide safe snacks/treats/lunches for student to keep in school if applicable.
○ provide wipes for classmates to use entering room in a.m. and after lunch if
necessary.
○
Nurse will:
○ meet with parent, teacher, and appropriate staff to develop a prevention plan.
○ discuss posting signage (as appropriate)Elementary classroom.
○ work with teacher(s) to protect the student from the use of peanuts/tree nuts or in
classroom snacks, curriculum, educational tools, classroom parties, foreign language
projects, and arts and crafts projects.
○ educate school staff who interact with student regarding food allergy, allergic reaction
symptoms, recognizing signs and symptoms of anaphylaxis, and prevention and
treatment plans. Post location of stock and student epinephrine auto-injector in Health Office.
○ obtain medication orders for any medications needed in school:
□ Epinephrine Auto-injector □ Benadryl □ Other:
○ Student Epinephrine location: □ Health Office □ Classroom □ Self-administer
○ train school staff in epinephrine auto-injector administration, as appropriate.
○ develop and disseminate emergency care plan for student(including transportation as
necessary) including MD orders or F.A.A.P.
○ (add use of walkie-talkie if appropriate and specific to student).
○review cleaning/care of nut/peanut free table in cafeteria with cafeteria and custodial
staff as needed
○ review with student, at least annually, his/her knowledge of the symptoms of anaphylaxis
and skills needed for self- administration of an epinephrine auto injector, including
practice in injecting anepinephrine auto injector into an appropriate practice tool as age
appropriate.
○ direct emergency actions in the event of anaphylaxis.
Teacher(s)/classroom staff will:
○ work to protect student from the use of the allergen in classroom snacks, curriculum,
educational tools, classroom parties, foreign language projects, and arts and crafts
projects ○ be trained in the administration of epinephrine auto injector, as appropriate.
○ consult at least 3 weeks in advance of field trips with the school nurse and parent/legal
guardian to decide what accommodations are appropriate for each field trip.
○ [for food allergens other than peanut/nut] notify parent/legal guardian in advance
regarding curriculum/projects that may contain:______[add food allergen].
○ note and prepare for allergic reaction if responsible for before and after school programs
○ manage unplanned classroom treats (if allowed) by: ______
______
○ encourage food free celebrations, but notify parents in advance of any in-class food
celebrations.
○ follow the emergency care plan if student has a reaction.
○
Student will:
○ not eat any foods except those that come from home or have been approved by the
parent/legal guardian.
○ inform teacher/staff if he/she is not feeling well, for any reason, but especially of he/she
thinks he/she may be having an allergic reaction. / (Enter the date(s) for all applicable interventions)
Assessment
Date/Nurse / Functional Health
Concern / Student
Objective(s) / Interventions / Evaluation
______will appropriately initiate self -administration of emergency medications andimmediately notify an adult and cooperate with staff administration of the ECP and emergency medications in the event of suspected ingestion of ______100 % of the time. / Students carrying their own medications:
○Follow the plan for self-administration of epinephrine auto injector and Benadryl. Accordingly, student will bring medication to and from school, and at all times carry (e.g., in belt-carrying case, purse) an up-to-date epinephrine auto injector (and appropriate Benadryl), according to the authorized prescriber’s order. (Example:If a student chooses to keep emergency medications in her purse, she will keep the purse with her at all times in school, during extracurricular activities, and on field trips.)
○ not self-administer Benadryl or epinephrine auto injector without immediately notifying the school nurse, or another responsible adult, in the absence of the school nurse.
○ not keep any medication in his/her locker.
○ participate with school nurse in annual review of emergency self-administration of
medication plan and implementation skills.
○
○
If You See This: Do This:
  1. Student states (or thinks) that he/she ate/ Stay with student.
was stung by/ allergen (list): Remain calm.
Call for help.
2. Signs and symptoms of allergic reaction may include:
Generalized flush, paleness, or swelling Administer Medication as
Hives, rash ordered:
Coughing, wheezing, difficulty breathing, □EpiPen
tightness of throat □ Adrenaclick
Difficulty swallowing, change in voice □ Twinject
Vomiting-Nausea-Abdominal Cramps-Diarrhea □ Benadryl
Turning blue esp. extremities-lips □ Auvi-Q
Swelling/tingling/itching of eyes, face, lips, □ Other:
tongue or mouth
Dizziness/passing out/become unresponsive CALL 911
Anxiety
IF AN EMERGENCY OCCURS:
1. phrine If the emergency is life-threatening, immediately call 9-1-1 preferably using a land line. Use cellphone for emergency back-up for a 911 call if land line not available. (Cell phone may not directly connect to local services.) Tell dispatcher that Epinephrine has been given for anaphylaxis.
  1. State who you are. b. State where you are. c. State problem.
2.Stay with the student or designate another adult to do so.
3.Call or designate someone to call the principal and/or school nurse.
4.Call or designate someone to call parents/legal guardians.
The following staff members are trained to manage an emergency, and initiate the appropriate procedures:

Nurse: ______RN Nurse: ______LPN Date: ______

Reviewed by: Parent: ______Date: ______Student: ______Date: ______

IHCP meeting attendees: ______

Comments: ______Mb11/2012

911 to be called if epinephrine auto injectoradministered