The following plans for the administration of EPIPEN injections must be carried out:

1. An Epipen/Allergy Medical Request Form must be completed annually and returned to the school nurse/teacher at the beginning of the school year.

a. At the elementary level, a Food Allergy Waiver form will be completed at the beginning of each year.

2. At least one (1) Epipen must be brought to the school for placement for immediate use by all school staff. If the student has been authorized to carry his/her own Epipen, at least one (1) additional Epipen should be made available to the school staff for access.

3. If other anti-allergic medications are required other than the Epipen, the appropriate medical release form must be completed by the physician and the parent.

4. The school nurse teacher in each school shall train and/or retrain all personnel responsible for children for whom an Epipen has been ordered and inform the faculty and staff regarding the symptoms of allergic reactions (anaphylaxis) in an effort to identify such reactions and the procedure to be followed.

5. During the first two weeks of school, a meeting may be held with the school nurse teacher, teacher/s, principal, other personnel, and parent to review the child’s medical status. An Emergency Care Plan/Individual Health Plan will be developed.

6. The school nurse teacher in the high school and the middle school may meet with students who have severe allergies in order to discuss the administration of an Epipen. Instruction may be provided and student demonstration with an Epipen trainer will be documented.

7. At all times, each school shall have available at least one person who is trained and competent in the administration of the epinephrine auto-injector other than the school nurse teacher.

In a case of anaphylaxis, the certified school nurse teacher shall administer the epinephrine auto-injector in accordance with standard nursing practice. School personnel who have been trained in accordance with training protocols are authorized to administer the epinephrine auto-injector to an identified student. If trained school personnel are not available, any willing person may administer the epinephrine auto-injector to an identified student. None of the requirements of this section shall preclude the self-administration of an epinephrine auto-injector by a medically identified student.

8. Training shall be provided annually for school personnel to administer an epinephrine auto-injector in case of anaphylaxis. Subjects to be covered shall include, but not be limited to: signs and symptoms of anaphylactic shock; proper epinephrine auto-injector storage (e.g., examining color, clarity and expiration date); proper epinephrine auto-injector dosage; proper epinephrine auto-injector administration; adverse reactions; accessing the “911” emergency medical system; and preparation for movement and transport of the student.

9. School administrators and/or school nurse teachers shall communicate the required medical information obtained from the parent/guardian and physician to the appropriate school personnel, including the certified school nurse teacher, teachers, food service workers, and bus personnel.

10. The school nurse teacher shall, annually at a minimum, log the expiration dates of the Epipens and periodically monitor the Epipens for evidence that the solution is viable.

11. Students who are treated for anaphylaxis at the school shall be transported promptly to an acute care hospital for medical evaluation and follow-up. Parents will be notified.

12. For a student with documented anaphylaxis, the parental authorization of a student’s allergy and the physician’s order to administer an epinephrine auto-injector shall be entered into the student’s health record and school health concerns list.

ADOPTED: 4/1/1996

REVISED: 6/15/2015




Name of Student: __________________________________ Date: ____________

Diagnosis for which medication is given: ___________________________________

If medication is to be given, describe indications: ______________________________________________________________________

1. Epipen Dosage 0.15 mg _____ 0.30mg ____

Route: IM Time: PRN

List significant side effects: _________________________________________

Other Information: ________________________________________________


May be self-carried Yes ____ No____

Self-Administered Yes ____ No ____

This Epipen will be administered by trained staff person accompanying child on a field trip or away from school activity.

2. Benadryl Dosage ________________

Route: PO Time: PRN

Other Information: ______________________________________________


May be self-carried Yes ____ No____

Self-Administered Yes ____ No ____

**Medication orders must be renewed prior to the start of each school year.

Physician Signature __________________________ Date__________________

I understand that special permission is required for the use of medication by students during school hours. I request that my child be given the above medication as prescribed by physician.

Parent Signature ______________________________ Date __________________

Revised 6/2015