San Francisco Unified School District
Report of Epinephrine Administration
Please complete for every instance in which epinephrine was administered at school.
Completed forms should be faxed to the Nurse of the Day @ 415-242-2615.
Student Demographics and Health History
1. School______Name of Person Receiving Epinephrine______
2. Birth Date:______Type of Person: Student Staff Visitor Gender: M F Grade:______
3. History of allergy: Yes No Unknown If known, specify type of allergy: ______
History of anaphylaxis: Yes No Unknown Diagnosis/History of asthma: Yes No Unknown
Previous epinephrine use: Yes No Unknown First time exposure: Yes No Unknown
School Plans and Medical Orders
4. Was an Allergy/Anaphylaxis Emergency Care Plan for current school year available? Yes No Unknown
Was a Medication Form for the current school year available? Yes No Unknown
5. Was this epinephrine district provided? Yes No
6. Expiration date of epinephrine ______Unknown
Epinephrine Administration Incident Details
7. Date/Time of occurrence: ______
8. If known, specify trigger that precipitated this allergic episode:
Food Insect Sting Exercise Medication Latex Other ______Unknown
If food was a trigger, please specify which food ______
Please check: Ingested Touched Inhaled Other specify ______
9. Did exposure begin prior to school? Yes No Unknown
10. Location where symptoms developed:
Classroom Cafeteria Health Office Playground Bus Other specify ______
11. How did exposure occur?
______
(Check all that apply)
Respiratory Gastro-Intestinal Skin Cardiac/Vascular Other
Cough Abdominal discomfort General swelling Chest discomfort Sweating
Difficulty breathing Diarrhea Flushing Bluish skin or lips Irritability
Hoarse voice Difficulty swallowing General itchiness Dizziness Loss of consciousness
Nasal congestion/rhinorrhea Itchy mouth/tongue General rash Weak pulse Metallic taste
Swollen throat or tongue Nausea Hives Headache Red eyes
Shortness of Breath Vomiting Lip swelling Hypotension Sneezing
Tightness in chest or throat Localized rash Rapid heartbeat
Wheezing Pale
Epinephrine Administration Incident Details (cont.)
12. First dose of epinephrine administered by: ______Title:______
Time first dose given: ______
Was first dose student supplied/Rx: Yes No Expiration date: ______
Was first dose stock/district supplied: Yes No Expiration date: ______
13. Second dose of epinephrine administered by: ______Title: ______
Time second dose given: ______
Was second dose student supplied/Rx: Yes No Expiration date: ______
Was second dose stock/district supplied: Yes No Expiration date: ______
14. Was a second dose of epinephrine required (biphasic reaction)? Yes No Unknown
If yes, was that dose administered at the school prior to arrival of emergency medical responders? Yes No Unknown
Approximate time between the first and second dose: ______
15. Time Emergency Medical Services (911) was notified: ______
Time of arrival of the emergency medical responders: ______
16. Parent Notified: (day/time)______Name of Parent Contacted: ______
Parent: At school Will come to school Will meet student at hospital Other:
Student Disposition
17. Transferred to an emergency room: Yes No Unknown Name of hospital: ______
If yes, transferred via: Ambulance Parent/Guardian Other ______
18. Hospitalized: Yes If yes, discharged after ______days No If no, discharged after ______min/hours
19. Student/Staff/Visitor outcome: ______
20. Other Comments:
Form completed by:______Date:______
(please print)
Position/Title:______
Phone number: (______) ______- ______Ext.: ______Email : ______
Please complete all questions and send completed form to School Health Programs, Nurse of the Day, fax 415 242-2618.
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6/2016 Revised and used with permission of the Massachusetts Department of Health, School Health Unit
Student, Family and Community Support Department 2016-2017 School Health Manual