WALNUT RIDGE PRIMARY SCHOOL 625 Route 517 P.O. Box 190 Vernon, NJ Voice (973) Fax (973)

WALNUT RIDGE PRIMARY SCHOOL 625 Route 517 P.O. Box 190 Vernon, NJ 07462 Voice (973) 764-2801 Fax (973) 764-0066 www.vtsd.com Rosemary Gebhardt Principal rgebhardt@vtsd.com Dear Parent/Guardian, The State of New Jersey revised the statute (NJSA 18A: 40-12.3-12.6) governing the emergency administration of epinephrine. This law was adopted because a school nurse may not be immediately available to assess the severity of an allergic reaction to administer epinephrine for pupils who cannot administer the medication themselves. According to the provisions, the parent/guardian must provide the following: Written authorization for the administration of a pre-filled single dose auto mechanism containing epinephrine. Written orders that the student requires the administration of epinephrine for anaphylaxis and does not have the capability for self-administration of the medication. Food Action Allergy Plan completed and signed by the physician and the parent/guardian. A signed statement from the parent/guardian acknowledging their understanding that Vernon Township Board of Education shall have no liability as a result of an injury arising from this administration. The parent/guardian is responsible to inform the school nurse of any school-sponsored activities that the student may be involved in throughout the year. The parent/guardian is responsible to provide the health office with a current, pre filled, single dose auto-injector mechanisms containing epinephrine and for replacing the mechanism when it has expired. Permission is effective for the current school year and must be renewed for each subsequent year. The State of New Jersey requires that every student with an epinephrine order be assigned a delegate, if the parent does not wish to have a delegate for their child, they must submit a written note. The delegate is NOT able to administer antihistamines such as Benadryl. We have attached the required forms for your completion. If you have any questions, please feel free to contact our office at 973-764-2808. Sincerely, Renate Gratzl RN

VERNON TOWNSHIP SCHOOLS Cedar Mountain Glen Meadow Lounsberry Hollow S. Fischer, R.N C. Insolera, R.N. D. Lisa, R.N.. 973-764-8781 973-764-2853 973-764-2869 Fax 973-764-0844 Fax 973-764-3295 Fax 973-764-0848 Rolling Hills Vernon Twp. H.S. Walnut Ridge D. Brown, R.N. B. Lipari, R.N. R. Gratzl, R.N. 973-764-2879 C. Toth, R.N. 973-764-2808 Fax 973-764-3284 973-764-2945/2949 Fax 973-764-0843 Fax 973-764-0858 FOOD ALLERGY ACTION PLAN PHYSICIAN ORDER Student s Name DOB Weight School Year ALLERGY TO Asthmatic? Yes* No * High risk for severe reaction SIGNS OF AN ALLERGIC REACTION Systems: Symptoms: MOUTH itching and swelling of the lips, tongue, or mouth/angioedema ANTIHISTAMINE EPINEPHRINE SKIN hives, itchy rash, and/or swelling of face or extremities ANTIHISTAMINE PINEPHRINE THROAT* itching and/or tightness in the throat, hoarseness and hacking cough ANTIHISTAMINE PINEPHRINE GUT nausea, abdominal cramps, vomiting, and/or diarrhea ANTIHISTAMINE EPINEPHRINE LUNG* shortness of breath, repetitive cough, wheezing or chest tightness ANTIHISTAMINE EPINEPHRINE HEART* thready pulse, passing out ANTIHISTAMINE EPINEPHRINE The severity of symptoms can change quickly. * All above symptoms can potentially progress to a life-threatening situation. ACTION FOR A MINOR REACTION 1. If only symptoms are rash or skin itching give Benadryl mg liquid OR tablets. 2. Then call emergency contacts on file in your school as provided by parents/guardians. POSSIBLE SIDE EFFECTS: SEDATION IF CONDITION DOES NOT IMPROVE WITHIN 10 MINUTES, FOLLOW STEPS FOR MAJOR REACTION + ACTION FOR MAJOR REACTION If ingestion is suspected and/or symptoms are cough, hoarseness of voice, tightness of voice, wheezing, and/or shortness of breath, immediately give: Twinjet autoinjector 0.3 mg syringe, entire contents Twinjet autoinjector 0.15 mg syringe, entire contents Epipen 0.3 mg syringe, entire contents Epipen 0.15 mg syringe, entire contents POSSIBLE SIDE EFFECTS: RAPID HEART RATE, JITTERINESS THEN CALL: 1. 911 and ask for advanced life support 2. Call emergency contacts on file as provided by parents/guardians. IF THERE IS INADEQUATE RESPONSE TO INITIAL EPINEPHRINE INJECTION WITHIN 10 MINUTES, ADMINISTER A SECOND DOSE. The student is both capable and responsible for self administrating this epinephrine: NO YES YES-WITH SUPERVISION The student must have access to epinephrine for any outside activities and school trips. IN THE ABSENCE OF THE SCHOOL NURSE, THE ORDER FOR BENADRYL SHOULD BE DISREGARDED AND EPINEPHRINE MAY BE ADMINISTERD BY A DESIGNATED SUBSTITUTE. Physician Signature Date

WALNUT RIDGE PRIMARY SCHOOL 625 Route 517 P.O. Box 190 Vernon, NJ 07462 Voice (973) 764-2801 Fax (973) 764-0066 www.vtsd.com Rosemary Gebhardt Principal rgebhardt@vtsd.com Delegate Orders Delegates are not permitted to administer antihistamines. Student s Name: D.O.B: Teacher: ALLERGY TO: Asthmatic Yes* No *Higher risk for severe reaction STEP 1: TREATMENT Symptoms : Give checked medication** ** To be determined by physician authorizing treatment If a food allergen has been ingested, but no symptoms: Epineph M outh Itching, tingling, or swelling of lips, tongue, mouth Epinephrine Skin Hives, itchy rash, swelling of the face or extremities Epinephrine Gut Nausea, abdominal cramps, vomiting, diarrhea Epinephrine Throat Tightening of throat, hoarseness, hacking cough Epine Lung Shortness of breath, repetitive coughing, wheezing Epine Heart W eak or thready pulse, low blood pressure, fainting, pale, blueness Epin Other Epine If reaction is progressing (several of the above areas affected), give Epine Potentially life-threatening. The severity of symptoms can quickly change. Dosage: Delegates are not permitted to administer antihistamines Epinephrine: inject intramuscularly (circle one): Epipen Epipen Jr. Twinjet 0.3 mg Twinjet 0.15 mg Auvi-Q o.15mg Auvi-Q 0.3 mg STEP 2: EMERGENCY CALLS 1. Call 911. State that an allergic reaction has been treated, and additional epinephrine may be needed. 2. Call parents or emergency contacts on file as provided by parents/guardians. EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY! Parent/Guardian Signature Date Doctor s Signature Date

VERNON TOWNSHIP SCHOOLS Cedar Mountain Glen Meadow Lounsberry Hollow S. Fischer R.N. C. Insolera, R.N. D. Lisa, R.N. 973-764-8781 973-764-2853 973-764-2869 Fax 973-764-3294 Fax 973-764-3295 Fax 973-764-0101 Rolling Hills Vernon Twp. H.S. Walnut Ridge D. Brown, R.N. B. Lipari, R.N. R. Gratzl, R.N. 973-764-2879 C. Toth, R.N. 973-764-2808 Fax 973-764-3284 973-764-2945/2949 Fax 973-764-0843 Fax 973-764-2961 PARENT RELEASE FORM ADMINISTRATION of EPINEPHRINE by DELEGATE SCHOOL EMPLOYEE Public Law 1997,c.368 (N.J.S.A. 18A:40-12.5) provides for training of a delegate school district employee to administer a pre-filled, single dose or double dose auto-injector mechanism containing epinephrine to a pupil who has a documented history of anaphylaxis when the nurse is not physically present and pupil does not have the capability for self-administration. The delegate employee will be trained by the School Nurse, in accordance to procedures specified in N.J.S.A.18A: 40-12.5. Parent Release: I parent/guardian of understand that the School Nurse may designate, (Name of student) in consultation with the Board of Education or Chief School Administrator, another employee of the school district to administer the epinephrine when the School Nurse is not physically present at the scene. (i.e.: after school activities) I acknowledge that if procedures specified in N.J.S.A. 18A:40-12.5 are followed, the school district shall have no liability as a result of any injury arising from the administration of a pre-filled, single dose auto-injector mechanism containing epinephrine by a designated employee. I shall indemnify and hold harmless the school district and its employees or agents against any claims arising out of the administration of such medication. Parents must provide: 1. Written order from Physician that the pupil requires the administration of epinephrine for anaphylaxis and documentation that the pupil does not have the capability for self-administration of the medication. 2. Parent must provide a current pre-filled single or double dose auto-injector mechanism containing epinephrine. Parent is responsible for replacing the mechanism when it has expired.

VERNON TOWNSHIP SCHOOLS Cedar Mountain Glen Meadow Lounsberry Hollow S. Fischer, R.N. C. Insolera, R.N. D. Lisa, R.N. 973-764-8781 973-764-2853 973-764-2869 Fax 973-764-3294 Fax 973-764-3295 Fax 973-764-0101 Rolling Hills Vernon Twp. H.S. Walnut Ridge D. Brown, R.N. B. Lipari, R.N. R. Gratzl, R.N. 973-764-2879 C. Toth, R.N. 973-764-2808 Fax 973-764-3284 973-764-2945/2949 Fax 973-764-0843 Fax 973-764-2961 Need for Administration of Epinephrine By School Employee other than School Nurse Pupils with a history of anaphylaxis, as documented by a physician, and do not have the capability for self-administration of the medication, may require the emergency administration of epinephrine for anaphylaxis P.L. 1997,c.368 (N.J.S.A. 18A-12.5) was adopted to enable the school nurse to delegate administration of epinephrine by another employee of the school district when the school nurse is not immediately available. Physician Statement Request for Delegate Administration of Epinephrine Name of student Grade School Name of Medication I have documented symptoms of anaphylaxis for (Name of student) Symptoms include This student does not have the capability for self-administration of this medication. Please arrange for delegate administration of above medication in the absence of the School Nurse. Signature of Physician Date

WALNUT RIDGE PRIMARY SCHOOL 625 Route 517 P.O. Box 190 Vernon, NJ 07462 Voice (973) 764-2801 Fax (973) 764-0066 www.vtsd.com Rosemary Gebhardt Principal rgebhardt@vtsd.com PARENTAL REFUSAL OF A DELEGATE FOR EPIPENPHRINE As per the State of New Jersey statute NJ8A: 40-12.5-12.6, this letter is to inform the Vernon Township School District that I do not wish for my child to have a delegate for his/her epinephrine administration. I am aware that a school nurse may not be immediately available to assess the severity of an allergic reaction to administer epinephrine for my child if he/she cannot administer it himself/herself. Parent Signature Date

WALNUT RIDGE PRIMARY SCHOOL 625 Route 517 P.O. Box 190 Vernon, NJ 07462 Voice (973) 764-2801 Fax (973) 764-0066 www.vtsd.com Rosemary Gebhardt Principal rgebhardt@vtsd.com Attention Physicians: The State of New Jersey revised the statute (NJ8A: 40-12.5-12.6) governing the emergency administration of epinephrine. This law was adopted because a school nurse may not be immediately available to assess the severity of an allergic reaction to administer epinephrine for pupils who cannot administer the medication themselves. According to the provisions, the parent/guardian must provide the following: The State of New Jersey requires that every student with an epinephrine order be assigned a delegate, if the parent does not wish to have a delegate for their child, they must submit a written note. The delegate is NOT able to administer antihistamines such as Benadryl. If the student needs antihistamine, an amendment should be added stating that if the nurse is not available the antihistamine can be omitted. Written authorization for the administration of a pre-filled single dose auto mechanism containing epinephrine. Written orders that the student requires the administration of epinephrine for anaphylaxis and does not have the capability for self-administration of the medication. Food Action Allergy Plan completed and signed by the physician and the parent/guardian. If you have any questions, please feel free to contact our office at 973-764-2808. Sincerely, Renate Gratzl RN MSHCS BSN CSN