5141.21 Form #8 5141.21 Form #8 Connecticut Statewide School Health Services ReportReport of Epinephrine* Administration
Please mail or fax form to: Stephanie Knutson, Connecticut State Department of Education, 25 Industrial Park Road, Middletown, CT 06457
Fax number: (860) 807-2127
School District: ____________________________________ Name of School:_____________________ Public [ ] Non Public0 [ ]
Student/Staff DOB: _____________Gender: M [ ] F [ ] Ethnicity: Spanish/Hispanic/Latino: Yes [ ] No [ ]
Race: American Indian/Alaskan Native [ ] African American [ ] Asian [ ] Native Hawaiian/other Pacific Islander [ ] White [ ]
Diagnosis/History of Asthma: Yes [ ] No [ ] History of Anaphylaxis: Yes [ ] No [ ] Previous Epinephrine Use: Yes [ ] No [ ]
Incident:
Date/Time of occurrence: ____________________________________________Known allergen(s):_________________________________
Trigger that precipitated this allergic episode: _____________________________________________________________________________
Symptoms:_______________________________________________________________________________________________________
Location of individual when symptoms developed: _________________________________________________________________________
Location of individual when Epinephrine administered: ______________________________________________________________________
Location of Epinephrine storage: ______________________________________________________________________________________
Epinephrine administered by: RN [ ] Other [ ] If other, please specify: _________________________________________________________
If other than an RN, was this person formally trained? Yes [ ] No [ ] Date of training:______________________________________________
If epinephrine was self-administered by an individual at school or a school-sponsored function, did the individual follow school protocols to notify school personnel and activate EMS? Yes [ ] No [ ] NA [ ]
Approximate time between onset of symptoms and administration of Epinephrine:__________________________________________________
Was Epinephrine administered under a patient specific order for a particular student? Yes [ ] [ ] No [ ]
Does school district have non-patient specific standing orders/protocols in pace for Anaphylaxis? Yes [ ] No [ ]
Individual Health Care Plan (IHCP) in place? Yes [ ] No [ ] School Physician notified? Yes [ ] No [ ]
Written school district policy on management of life-threatening allergies in place? Yes [ ] No [ ]
Disposition:
Transferred to ER: Yes [ ] No [ ] Discharged after _____ hours Biphasic reaction: Yes [ ] No [ ] Unknown [ ]
Hospitalized: Yes [ ] No [ ] Discharged after _____ days
Outcome:
Recommendations for changes/improvements to current policy or procedures:
Debriefing meeting? Yes [ ] No [ ]
Form completed by: _____________________________________________________ Date: ______________________
(please print)
Title: ________________________________________________________________ Phone number: _______________
Address: _________________________________________________________________________________________
*EpiPen®, or EpiPen® Jr. or Twinject™