JHCCB-E-3: Strategies in Prevention and Management of Anaphylaxis in the School Setting

Classification: 
J: Students
Code: 
JHCCB-E-3

APPENDIX A3

EMERGENCY ALLERGY ALERT FORM

(to be updated at the beginning of each school year)

Valid for school year:____________________________

Child’s Name: _________________________________

 Place Child’s Photo Here

 

 

Allergy - Description

This child has a DANGEROUS, life threatening allergy to the following:

 

In the case of food allergens: foods containing them in any amount are:

 

This child wears medical alert information located:

 

Avoidance

The key to preventing an emergency is ABSOLUTE AVOIDANCE of food allergens at all times.  WITHOUT EPINEPHRINE INJECTOR AVAILABLE, THIS CHILD MUST NOT BE ALLOWED TO EAT ANYTHING.

Eating Rules (List eating rules for your child in this space)

 

Symptoms:

Difficulty swallowing, swollen tongue, coughing (could sound like throat clearing), burning or itching throat, hives, generalized swelling, redness, itching, vomiting, breathing difficulties

 

Additional Symptoms:

 

Action:

If there are ANY suspicions that the child may have been in contact with an allergen:

  • Do not wait
  • Send a runner to IMMEDIATELY notify the child’s classroom teacher and the principal or designate to call an ambulance at ______.
  • Lay the child on the floor.
  • Get the epinephrine injector from the child’s fanny pack. 

HOW TO USE AN EpiPen:

  • Pull off gray safety cap on EpiPen.
  • Firmly press against OUTER MID-THIGH of child’s leg with the black tip end of the needle.  (This may be done through the child’s clothing, if necessary.)
  • Wait 10 seconds for fluid to enter body ( an accurate way to count: one-one thousand, two-one thousand,

  • Massage are for 10 seconds

  • A support person should send a runner to obtain additional EpiPen(s) stored in ________________.
  • A support person must accompany child during transport.
  • The child should be rushed to the hospital; additional EpiPens, if available, should be taken with the child should subsequent injections be required; i.e. if breathing becomes laboured once again. Epinephrine can be administered once every 15 minutes.

PHONE:

Call parents:

Mother:                                                                         Father:

Emergency Contact or Guardian:

Do Not Hesitate to Administer Medication or Call Ambulance Even If Parents Cannot Be Reached

This form, once completed, should be shared with every teacher who comes into contact with the Anaphylactic Child.