Matawan-AberdeenRegionalSchool District
CAMBRIDGEPARK PRESCHOOL
One Crest Way, Aberdeen, New Jersey07747
(732) 705-4000 FAX (732) 290-7938
Joseph G. Majka, J.D.Superintendent of Schools / Wayne Spells
Principal
PHYSICIAN’S ORDER FOR THE ADMINISTRATION OF EPINEPHRINE
Part 1: To be Completed by Physician
Student’s Name: ______D.O.B.______
School: ______Grade/Teacher: ______
I CERTIFY THAT THE ABOVE NAMED STUDENT IS ALLERGICTO______
______
Exposure to these allergens in the past: ____HAS resulted in ANAPHYLAXIS
____HAS NOT resulted in ANAPHYLAXIS
Asthmatic: ____Yes ____No
TREATMENT
Symptoms: Give Checked Medication
- If a food allergen has been ingested, but no symptoms: ___Epinephrine ___Antihistamine
- Mouth Itching, tingling, or swelling of lips, tongue, mouth ___Epinephrine ___Antihistamine
- Skin Hives, itchy rash, swelling of the face or extremities ___Epinephrine ___Antihistamine
- Gut Nausea, abdominal cramps, vomiting, diarrhea ___Epinephrine ___ Antihistamine
* Throat - Tightening of throat, hoarseness, hacking cough ___Epinephrine ___ Antihistamine
* Lung - Shortness of breath, repetitive coughing, wheezing ___Epinephrine ___Antihistamine
* Heart -Thready pulse, low blood pressure, fainting, pale, blueness ___Epinephrine ___Antihistamine
*The severity of symptoms can quickly change.
If reaction is progressing (several of the above areas affected), give ___Epinephrine ___Antihistamine
DOSAGE:
Epinephrine(circle one): 0.3mg 0.15mg
Antihistamine: ______
Medication/dose/route
Check all that apply:
_____ Student has been trained in procedure and may carry and self-administer Epi-Pen
_____ Student has been instructed in symptom recognition, is capable of, and may self-administer
Benadryl according to N.J.S.A. 18A:40-12.3
_____ Benadryl (if prescribed) may be OMITTED from the above plan ON A FIELD TRIPwhen a nurse or parent does not attend the trip and when student is not certified to self administer. In accordance with N.J.S.A. 18A:40-12.6, a designee of the school nurse who has been properly trained in the administration of the epi-pen will attend all field trips when the nurse or parent/guardian does not attend.
Date: ______Physician’s Signature______
ADMINISTRATION OF MEDICATION FOR ANAPHYLAXIS
PARENT/GUARDIAN CONSENT
School Nurse:
I hereby request that the school nurse administer the medication specified on page 1 of this form as directed by my physician to my child______. I will supply the medicine in an ORIGINAL CONTAINER and will notify the school nurse promptly of any changes in this order.
______
DATESIGNATURE OF PARENT/GUARDIAN
Self-Administration of Medication:
I verify that my son/daughter has my permission to self-administer the medication specified on page 1 of this form. (CERTIFICATION MUST BE PROVIDED FROM STUDENT’S PHYSICIAN ACKNOWLEDGING PUPIL HAS BEEN INSTRUCTED IN THE PROPER METHOD OF SELF-ADMINISTRATION OF MEDICATION)
______
DATESIGNATURE OF PARENT/GUARDIAN
Designee of School Nurse:
This is to verify that the designees of the school nurse who have been properly trained in the administration of the medication for anaphylaxis have my permission to administer said medication to my son/daughter.
______
DATESIGNATURE OF PARENT/GUARDIAN
Waiver of Liability (waiver must be signed by parent/guardian in order for administration of medication by nurse, designee or self-administration by pupil)
I agree that if the procedures specified in Board Policy 5141.21 and 5141.21R regarding administration of medication are followed, the school district and its employees or agents shall incur no liability as a result of any injury.
______
DATESIGNATURE OF PARENT/GUARDIAN