Allergy to: Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No For a suspected or active food allergy reaction:

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1 Name: D.O.B.: Allergy to: Weight: lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No For a suspected or active food allergy reaction: PLACE STudent s Picture here SEVERE SYMPTOMS [ ] if checked, give epinephrine immediately if the allergen was definitely eaten, even if there are no symptoms. NOTE: WHEN IN DOUBT, GIVE EPINEPHRINE. mild SYMPTOMS [ ] if checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten. LUNG Short of breath, wheezing, repetitive cough HEART Pale, blue, faint, weak pulse, dizzy THROAT Tight, hoarse, trouble breathing/ swallowing MOUTH Significant swelling of the tongue and/or lips NOSE Itchy/runny nose, sneezing MOUTH Itchy mouth SKIN Many hives over body, widespread redness 1. INJECT EPINEPHRINE IMMEDIATELY. 2. Call 911. Request ambulance with epinephrine. Consider giving additional medications (following or with the epinephrine):»» Antihistamine GUT Repetitive vomiting or severe diarrhea»» Inhaler (bronchodilator) if asthma Lay the student flat and raise legs. If breathing is difficult or they are vomiting, let them sit up or lie on their side. If symptoms do not improve, or symptoms return, more doses of epinephrine can be given about 5 minutes or more after the last dose. Alert emergency contacts. OTHER Feeling something bad is about to happen, anxiety, confusion Or a combination of mild or severe symptoms from different body areas. NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. Use Epinephrine. ò ò ò Transport student to ER even if symptoms resolve. Student should remain in ER for 4+ hours because symptoms may return. SKIN A few hives, mild itch ò ò ò GUT Mild nausea/discomfort 1. Give Antihistamines, If Ordered By Physician 2. Stay with student; alert emergency contacts. 3. Watch student closely for changes. If symptoms worsen, GIVE EPINEPHRINE. MEDICATIONS/DOSES Epinephrine Brand: Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM Antihistamine Brand or Generic: Antihistamine Dose: Other (e.g., inhaler-bronchodilator if asthmatic): Parent/Guardian Authorization Signature Date Physician/HCP Authorization Signature Date Form provided courtesy of Food Allergy Research & Education (FARE) ( 8/2013

2 EpiPen (epinephrine) Auto-Injector Directions 1. Remove the EpiPen Auto-Injector from the plastic carrying case. 2. Pull off the blue safety release cap. 3. Swing and firmly push orange tip against mid-outer thigh. 4. Hold for approximately 10 seconds. 5. Remove and massage the area for 10 seconds. 2 4 Auvi-Q TM (epinephrine injection, USP) Directions 1. Remove the outer case of Auvi-Q. This will automatically activate the voice instructions. 2. Pull off red safety guard. 3. Place black end against mid-outer thigh. 4. Press firmly and hold for 5 seconds. 5. Remove from thigh. 2 3 Adrenaclick /AdrenaclicK Generic Directions 1. Remove the outer case. 2. Remove grey caps labeled 1 and Place red rounded tip against mid-outer thigh. 4. Press down hard until needle penetrates. 5. Hold for 10 seconds. Remove from thigh OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.): Treat student before calling Emergency Contacts. The first signs of a reaction can be mild, but symptoms can get worse quickly. Emergency Contacts call 911 Rescue Squad: Doctor: Phone: Parent/Guardian: Phone: Other Emergency Contacts Name/Relationship: Phone: Name/Relationship: Phone: Parent/Guardian Authorization Signature Date Form provided courtesy of Food Allergy Research & Education (FARE) ( 8/2013

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4 Bee Sting Allergy Action Plan Student s Name: D.O.B: Grade/Class ALLERGY TO: Asthmatic Yes* No *Higher risk for severe reaction Place Child s Picture Here STEP 1: TREATMENT Symptoms: Give Checked Medication**: **(To be determined by physician authorizing treatment) If child has been stung, 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 Other Epinephrine Antihistamine If reaction is progressing (several of the above areas affected), give Epinephrine Antihistamine The severity of symptoms can quickly change. Potentially life-threatening. DOSAGE Epinephrine: inject intramuscularly (circle one) EpiPen EpiPen Jr. Twinject 0.3 mg Twinject 0.15 mg (see reverse side for instructions) Antihistamine: give Other: give 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. at 3. Emergency contacts: Name/Relationship Phone Number(s) a. 1.) 2.) b. 1.) 2.) c. 1.) 2.) EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY! Parent/Guardian Signature Date

5 TRAINED STAFF MEMBERS 1. Room 2. Room 3. Room EpiPen and EpiPen Jr. Directions Pull off gray activation cap. Twinject 0.3 mg and Twinject 0.15 mg Directions Hold black tip near outer thigh (always apply to thigh). Pull off green end cap, then red end cap. Put gray cap against outer thigh, press down firmly until needle penetrates. Hold for 10 seconds, then remove. Swing and jab firmly into outer thigh until Auto-Injector mechanism functions. Hold in place and count to 10. Remove the EpiPen unit and massage the injection area for 10 seconds. SECOND DOSE ADMINISTRATION: If symptoms don t improve after 10 minutes, administer second dose: Unscrew gray cap and pull syringe from barrel by holding blue collar at needle base. Slide yellow or orange collar off plunger. Put needle into thigh through skin, push plunger down all the way, and remove. Once EpiPen or Twinject is used, call the Rescue Squad. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours. For children with multiple food allergies, consider providing separate Action Plans for different foods. **Medication checklist adapted from the Authorization of Emergency Treatment form developed by the Mount Sinai School of Medicine. Used with permission.

6 Food Allergy Action Plan Student s Name: D.O.B: Teacher: ALLERGY TO: Asthmatic Yes* No *Higher risk for severe reaction Place Child s Picture Here 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 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 Other Epinephrine Antihistamine If reaction is progressing (several of the above areas affected), give Epinephrine Antihistamine The severity of symptoms can quickly change. Potentially life-threatening. DOSAGE Epinephrine: inject intramuscularly (circle one) EpiPen EpiPen Jr. Twinject 0.3 mg Twinject 0.15 mg (see reverse side for instructions) Antihistamine: give Other: give 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. at 3. Emergency contacts: Name/Relationship Phone Number(s) a. 1.) 2.) b. 1.) 2.) c. 1.) 2.) EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY! Parent/Guardian Signature Doctor s Signature (Required) Date Date

7 TRAINED STAFF MEMBERS 1. Room 2. Room 3. Room EpiPen and EpiPen Jr. Directions Pull off gray activation cap. Twinject 0.3 mg and Twinject 0.15 mg Directions Hold black tip near outer thigh (always apply to thigh). Pull off green end cap, then red end cap. Put gray cap against outer thigh, press down firmly until needle penetrates. Hold for 10 seconds, then remove. Swing and jab firmly into outer thigh until Auto-Injector mechanism functions. Hold in place and count to 10. Remove the EpiPen unit and massage the injection area for 10 seconds. SECOND DOSE ADMINISTRATION: If symptoms don t improve after 10 minutes, administer second dose: Unscrew gray cap and pull syringe from barrel by holding blue collar at needle base. Slide yellow or orange collar off plunger. Put needle into thigh through skin, push plunger down all the way, and remove. Once EpiPen or Twinject is used, call the Rescue Squad. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours. For children with multiple food allergies, consider providing separate Action Plans for different foods. **Medication checklist adapted from the Authorization of Emergency Treatment form developed by the Mount Sinai School of Medicine. Used with permission.

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