Mount Olive School District

PHYSICIAN ORDERS FOR MEDICATION TO BE GIVEN AT SCHOOL

Student”s Name:______Age____Grade____

Student’s Address:______

Diagnosis:______

Medication:______

Dosage:______

Frequency:______

**If medication is for Asthma, Diabetes, Anaphylaxis or other life threatening conditions, may student carry and self-administer? Yes___ No___

**May student omit medication during field trips? Yes___ No___

**Must medication be given on school half days? Yes___ No___

** “I give permission for the School Nurse to inform the appropriate staff members of my child’s medical condition(s) or special need(s).” Yes___No___

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Physician Certification for Self-Medication Pursuant to

N.J.S.A. 18A:40-12.3

I certify that suffers from , a

(student) (condition)

potentially life-threatening illness. I have discussed the administration of this medication with the above named student; and I certify that he/she is capable of, and has been instructed in, the proper method of self-administration of the medication in an emergency situation as directed above.

______

Physician's Signature Date

______

Physician's Name (please print) Address

Phone FAX

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Parent Acknowledgement and Authorization Pursuant to

N.J.S.A. 18A:40-12.3

I hereby authorize the above-named student to self-administer medication in potentially life threatening situations as evidenced by my submission of the above Physician Certification.

By also signing the Acknowledgement, I understand that the Board of Education, its employees or agents shall incur no liability as a result of any injury arising from the self-administration or medication of the student; and I hereby indemnify and hold harmless the Board and its offices, employees and agents against any claims arising out of the self-administration of medication by my child.

Parent or Guardian Signature Date

Parent's or Guardian's Name (please print) Student's Name (please print)

Allergy Action Plan

Student’s

Name:______D.O.B:______Teacher:______

ALLERGY TO:______

Asthmatic Yes No

Previous episode of anaphylaxis Yes No

STEP 1: TREATMENT

Symptoms: / Give Checked Medication**:
**(To be determined by physician authorizing treatment)
· 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
· GI: 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: Weak or thready pulse, low blood pressure, fainting, pale, cyanosis / Epinephrine Antihistamine
· Other: ______/ Epinephrine Antihistamine
· If reaction is progressing (several of the above areas affected), give: / Epinephrine Antihistamine

†Potentially life-threatening. The severity of symptoms can quickly change.

DOSAGE

Epinephrine: inject intramuscularly (circle one) EpiPen® 0.3mg EpiPen® 0.15mg Jr. Twinject® 0.3 mg Twinject® 0.15 mg (see reverse side for instructions)

Antihistamine: give______

medication/dose/route

Other: give______

medication/dose/route

IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis.

STEP 2: EMERGENCY CALLS

1. Call 911 (or Rescue Squad: ______). State that an allergic reaction has been treated, and additional epinephrine may be needed.

2. Dr. ______Phone Number: ______

3. Parent______Phone Number(s) ______

4. Emergency contacts:

Name/Relationship Phone Number(s)

a. ______1.)______2.) ______

b. ______1.)______2.) ______

EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY!

Parent/Guardian’s Signature______ Date______

Doctor’s Signature______Date______

(Required)

INDIVIDUAL STUDENT HEALTH PLAN FOR ANAPHYLAXIS

NAME SCHOOL GRADE

SCHOOL YEAR HOMEROOM TEACHER

A. Diet

Allergic to:

X - indicate items that are components of the student's heath plan.

_____ The student must be informed by the family and physician about foods to avoid.

_____ The student may not eat any foods during the school day except as provided by the home.

_____ The student brings lunch from home.

_____ Snacks supplied from home will be kept in the homeroom and used as needed during the school day.

_____ The student may not come in contact with offending food(s):

_____ smell _____ feel _____ taste _____touch

_____ Cleaning of school furniture is required prior to student use if known food contamination has occurred.

Note: the classroom teacher notifies the custodian of the need for cleaning furniture due to food contamination.

_____ Other

B. Classroom/School Routines and Activities

_____ The student's epinephrine auto-injector will be located:

(please check) _____ fanny pack* _____ notebook case ____ health office

_____ main office _____ back pack ____ other______

____ The student is transported by school bus # .

_____ The student drives to school.

_____ The parents transport the student to and from school.

_____ The student walks to and from school.

_____ Parent or designee should attend school functions beyond the school day; e.g., plays, concerts, family nights where refreshments/snacks are typically provided.

_____ Parent is required to inform the school nurse in writing at least 2 weeks prior to attending any school function before or after the school day (i.e. field trips, concerts, plays).

_____ Other special needs

* Note: Having the auto-injector carried in a fanny pack on the student's person is the recommended option that ensures availability of the epinephrine at all times.

C. Response to an Episode

_____ The adult in charge calls or designates another adult to call 911. The caller must specify

that the student is experiencing anaphylaxis.

_____ Simultaneously to the call to 911, epinephrine via auto-injector is administered by the

school nurse, principal or trained volunteer in the school.

______Follow up is carried out by the appropriate personnel including transportation to the nearest

hospital emergency room by emergency medical personnel when appropriate.

_____ Other

School Nurse's Signature Date

Parent/Guardian's Signature Date

When the school nurse is not available, I(we)

(Mother)

the parents/guardians of

(Father) (Child)

authorize the administration of epinephrine via auto-injector to my child by a designated staff member trained by the school nurse. I understand that the Mt. Olive School District shall have no liability as a result of any injury arising from the administration of the epinephrine via the auto-injector to the child. I/we indemnify and hold harmless the district and its employees or agents against any claims arising out of the administration of the epinephrine auto-injector to my child.

Parent/Guardian's Signature Date