Sensitivity Insect Allergic Reaction Action Plan

Medically Diagnosed
Sensitivity / Allergic Reaction - Insect
Anson Independent School District
Health Services Department

Parent/Guardian(s)-

For students with medically diagnosed Anaphylaxis an effort to meet student needs and still maintain a safe environment with regard to medications in the school setting, the following procedures have been developed and incorporated into school health services program and must be renewed annually.

Sensitivity – Insect Allergic Reaction Action Plan

Parent/Physician Authorization for Self-Administration of Allergic Reaction Medication by a Studentforms (attached) must be completed as follows:

Completed and signed by student’s physician
Parent read and signature
Return to nurse’s office

Each student that has a Sensitivity - Insect Action Plan must also have an Emergency Contact Information and Consent (attached) on file in the nurse’s office.

This information is to be provided by the parent/guardian, including the parent/guardian(s) signature.

Please return all completed documents to the nurse’s office.

All medications and supplies may also be delivered once documents are on file.

Medications will need to be in original container with prescription label attached.
Medications, and supplies need to be placed in storage (Ziplock® type) bag with student’s name placed on outside.
All medications and supplies will need to be picked up on or before the final day of class.
All unclaimed medications will be discarded at the end of the school year.
There will be NO medications kept in the clinic through the summer months.

Should you have any questions, I can be reached Monday-Friday 8am-3pm at 823-4475. I appreciate your help in providing the necessary information needed to provide the best possible care to your child.

Thank you,

Michelle Huffaker, RN

Anson ISD Health Services Department

Allergic Reaction/Sensitivity - Insect
Anson Independent School District
Health Services Department

Upon receipt of the health history information for your child, it was noted that your child had insect sensitivity – allergies reaction. Becauseallergies ofthis type can be serious, please provide a description of thereaction your child experiences in the space provided below.

If you wish the school nurse and/or other Anson ISD personnel to administer medication, please sign and return this form to my office located in the Elementary building.
If you do not wish for medication/treatment to be administered to your child at school, please sign and return the waiver of treatment portion to my office.

If your child has severe (breathing difficulties) allergicreactions, I urge you to discusswith your doctor the possible need of keeping an Epi-pen (medication to be used only in the event ofa life-threatening allergic response) at school.

The nurse'soffice does NOT stock a single dose of epinephrine.

Insect Sensitivity

Insect Type: ______Type of Reaction: □ Breathing Difficulty □ Rash□ Hives

______

Parent/Guardian SignatureDate

**********************************Waiver of Treatment************************************************

My child, ______has a severe allergic reaction to ______. I have been informed by school personnel of the required documentation needed to properly treat ______while at school and/or school related events. I understand that it is my responsibility to provide all needed information. However, I decline to participate in the requirements. Therefore, I do hereby agree to indemnify and save harmless the school and any school representative from any liability arising in the event that my child, ______have an anaphylaxis reaction.

______

Parent SignatureDate

AISDFormXA,7/09

Allergic Reaction/Sensitivity – Insect
Emergency Action Plan
Anson Independent School District
Health Services Department

Insect Sensitivity to:

Insect: ______Type of Reaction: □ Breathing Difficulty □ Rash□ Hives

Has Student been diagnosed with Asthma? □ Yes □ No Medication given at school: ______

Symptoms Emergency Treatmentto be completed by Physician
Mild Symptoms (Local reaction)
* Mild skin reactions Hives/Swelling only
in the areas of
allergen contact.
Students with an Epi-pen or history of anaphylaxis must go home
With parental supervision for the remainder of the school day.
SYMPTOMS CAN BECOME MORE SERIOUS VERY QUICKLY OR OVER THE NEXT SEVERAL HOURS.
/ »IF STUDENT HAS MILD SYMPTOMS OR INGESTED IS SUSPECTED: CALL 911

Note time ______and stay with student
Watch closely for serious symptoms
Give ______as ordered by physician
Call parent or emergency contact
Stay with student until parent or EMS arrives
Call school nurse

DO NOT HESITATE TO CALL 911 OR TO GIVE EMERGENCY MEDICATION(S)

SERIOUS SYMPTOMS (Systemic Reaction):

Skin widespread hives and flushing, widespread

swelling

Mouth swelling of the tongue
Throat itching, or a sense of tightness of the throat,

Hoarseness, hacking cough

Gut vomiting, nausea, cramps, diarrhea
Lungs repetitive coughing, wheezing, trouble breathing
Heart rapid heart rate, lightheadness, dizziness, loss of

consciousness / IF STUDENT HAS ANY SERIOUS SYMPTOMS:

Note time ______and stay with student
Give ______as ordered by physician
Administer Epi-pen. Follow directions on injection

Device as trained. Note time given ______

Call 911: ask for Advance Life Support for an

Allergic reaction

Call parent or emergency contacts
Call school nurse

This Emergency Action Plan must be signed by both parent/guardian and physician

My signature below shows I reviewed and agree with this plan.

______

Parent Signature Date Physician Signature Date

______

Physician’s Printed Name

Allergic Reaction/Sensitivity – Insect
Emergency Contact Information and Consent
Anson Independent School District
Health Services Department

Student Name: ______Teacher ______

Student Food Allergies: ______

______

Student Medication Allergies: ______

______

Grade: ______Male: ___ Female: ___ Date of Birth: ______

Address: ______Home Phone: ______

______Cell Phone: ______

______Emergency No.: ______

Father’s Name: ______Work Phone: ______Cell Phone ______

Mother’s Name: ______Work Phone: ______Cell Phone ______

In case parents can not be reached at time of emergency, please call:

Name: ______Phone: ______

Relationship to student: ______Phone: ______

Name: ______Phone: ______

Relationship to student: ______Phone: ______

Unfortunately, there is always the possibility of an accident occurring to a student at school or while participating in an after-school activity. In case an accident should occur, the school and/or the UIL does not assume responsibility. Nevertheless, if an accident should occur, a discretionary judgment will be made by a school representative in regard to the student’s need for immediate care and treatment. Therefore, I do herby request, authorize, and consent to such care and treatment as may be given to the said student by and physician, trainer, nurse or school representative. As well, I do hereby agree to indemnify and save harmless the school and any school representative from any claim by any person whomsoever on account of such care and treatment of the said student.

Between this date and the end of the school year, illness or injury could occur that may limit the student’s participation, I agree to notify the school authorities of such illness or injury.

______

Signature of Parent/Guardian Date

______

Signature of Parent/GuardianDate

Allergic Reaction/Sensitivity – Insect
Parent/Physician Authorization for Self-Administration of Allergy Medication
By a Student
Anson Independent School District
Health Services Department
Parent Authorization
I have reviewed the attached guidelines and procedures for Self-Administration of Prescription Anaphylaxis Medication by Students; discussed them with my child; and request that my child be able to possess and self-administer his/her prescription anaphylaxis medication while on school property or at a school-related event or activity. I understand that the anaphylaxis medication must be prescribed for my child as indicated on the prescription label, which must be affixed to the medication container (inhaler canister or packaging box). I release the school district and employees of any liability arising from self-administration.
______
Parent/Guardian Signature Date
Physician Authorization
The medical history and my examination of ______,
Students Name
indicates that he/she does have anaphylaxis. The student has been educated and is knowledgeable about his/her anaphylaxis and can properly self-administer the prescribed medication and determine its effectiveness.
Name of Medication: ______
Purpose of Medication: ______
Prescribed Dosage: ______
Times at which or circumstances under which the medicine may be administered:
______
______
______
______
Period of time for which the medicine has been prescribed:
□ Long Term (chronic condition)
□ Short Term and should be discontinued by ______
Date
______
Physician’s Printed Name Physician’s Signature
Office Telephone Number: ______
Diagnosed Medical Condition
Insect Sensitivity – Allergic Reaction
Waiver of Treatment
Anson Independent School District

My child, ______has been medically diagnosed and/or treated

for Insect Sensitivity – Allergic Reaction and I have been informed by Anson ISD, school personnel of the requireddocumentation needed to properly treat him / her while at school and/or school related events. I understand that it is my responsibility to provide to the school all needed information and

medication. However, I decline to participate in the requirements. Therefore, I do herby agree

to indemnify and save harmless the Anson ISD and any of its representatives from any liability

arising in the event that my child, listed above, have an Insect Sensitivity and/or Allergy-like related episode.

______

Parent SignatureDate

______

Parent Printed NamePhone Number