FOOD ALLERGY MANAGEMENT MANUAL by vqx13199

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									   FOOD ALLERGY
MANAGEMENT MANUAL
    Special Services
    Farmington Public Schools
    Food Allergy Management
            Contents

Food Allergy Management Plan and Guidelines
School Nurse Letter
Emergency and Health Care Plans Outline
How a Child Might Describe a Reaction
Individual Health Care Plan
Individual Health Care Plan Sample
Emergency Care Plan for Non-Anaphylactic Conditions
Current Health Status and Individualized Emergency Plan for
Students with Special Needs
Medical Statement for Children With Disabilities
Medical Statement for Children Without Disabilities
Treatment Plan and Permission for the Administration of
Medications by School Personnel
Risk Assessment Questions; Grades K-4 Field Trips
Risk Assessment Questions; Grades 5-12 Field Trips
Emergency Response Protocol
Emergency Response Protocol Sample
Health Services Self-Medication Assessment
Connecticut General Statues
                         FARMINGTON PUBLIC SCHOOLS
                FOOD ALLERGY MANAGEMENT PLAN AND GUIDELINES

The following Food Allergy Management Plan and Guidelines support Board of Education
Policy 6142.101a: Student Nutrition and Physical activity and Policy 5141 Health Services.

The Farmington Public Schools recognize that food allergies may be life threatening. For
this reason, the district is committed to developing strategies and practices to minimize the
risk of accidental exposure to life threatening food allergens and to ensure prompt and
effective medical response should a child suffer an allergic reaction while at school. The
district further recognizes the importance of collaborating with parents and appropriate
medical staff in developing such practices and encourages strategies to enable the student to
become increasingly proactive in the care and management of his/her food allergy, as
developmentally appropriate. Likewise, implementation of appropriate interventions will
endeavor to maintain a balance among individual, school and community needs and to foster
the normal development of the child. To this end, the Farmington Public Schools adopt the
following guidelines related to the management of life threatening food allergies for students
enrolled in district schools.


I. Identifying Students with Life-Threatening Food Allergies

            Early identification of students with life-threatening food allergies is important. The
            district therefore encourages parents/guardians of children with a life-threatening
            food allergy to notify the school of the allergy, providing as much information about
            the extent and nature of the food allergy as is known, as well as any known effective
            treatment for the allergy.


II. Individualized Health Care Plans and Emergency Care Plans


            A. If the district determines that a child has a life-threatening food allergy, the
               district shall develop an Individualized Health Care Plan (IHCP) for the child.
               Each IHCP should contain information relevant to the child’s participation in
               school activities, and should attempt to strike a balance between individual,
               school and community needs, while fostering normal development of the child.

            B. The IHCP should be developed by a group of individuals, which shall include the
               parents and appropriate school personnel. Such personnel may include, but are
               not limited to, the school nurse, school administrator, classroom teacher(s), school
               or food service administrator(s); and the student, if appropriate. The school may
               also consult with the school’s medical advisor and student’s physician, as needed.

            C. IHCPs are developed for students with special health needs or whose health needs
               require daily interventions. The IHCP describes how to meet the child’s health
               and safety needs within the school environment and should address the student’s


Rev. 9/06                                                                                             1
               needs across school settings. Information to be contained in an IHCP should
               include a description of the functional health issues (diagnoses); student
               objectives for promoting self care and age appropriate independence; and the
               responsibilities of parents, school nurse and other school personnel.

            D. The IHCP may also include strategies to minimize the student’s risk for exposure,
               such as considerations regarding:

                   1. classroom environment, including allergy free considerations;

                   2. cafeteria safety;

                   3. participation in school nutrition programs;

                   4. snacks, birthdays and other celebrations;

                   5. alternatives to food rewards or incentives;

                   6. hand-washing;

                   7. location of emergency medication;

                   8. risk management during lunch and recess times;

                   9. special events;

                   10. field trips;

                   11. extracurricular activities;

                   12. school transportation;

                   13. staff notification; and

                   14. transitions to new classrooms, grades and/or buildings.

            E. The IHCP should be reviewed annually, or whenever there is a change in the
               student’s emergency care plan, a change in self-monitoring or self-care abilities of
               the student, or following an emergency event requiring the administration of
               medication or the implementation of other emergency protocols.

            F. In addition to the IHCP, the district shall also develop an Emergency Care
               Protocol (ECP), sometimes referred to as an Emergency Response Protocol or
               ERP, for each child identified as having a life threatening food allergy. The ECP
               is part of the IHCP and describes the specific directions about what to do in a
               medical emergency. The ECP should include the following information:

                   1. the child’s name and other identifying information, including date of birth,
                      grade and photo, as made available;


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                   2. the child’s specific allergy;

                   3. signs and symptoms of an allergic reaction;

                   4. the medication, if any, or other treatment to be administered in the event
                      of exposure;

                   5. the location and storage of the medication;

                   6. who will administer the medication (including self-administration options,
                      as appropriate);

                   7. other emergency procedures, such as calling 911, contacting the school
                      nurse, and/or calling the parents or physician;

                   8. recommendations for what to do if the child continues to experience
                      symptoms after the administration of medication; and

                   9. emergency contact information for the parents/family and medical
                      provider.

            G. In developing the ECP, the school nurse should obtain current health information
               from the parents/family and the student’s health care provider, including the
               student’s emergency plan and all medication orders. If needed, the school nurse
               or other appropriate school personnel, should obtain consent to consult directly
               with the child’s health care providers to clarify medical needs, emergency medical
               protocol and medication orders.

            H. A student identified as having a life-threatening food allergy is entitled to an
               IHCP and an ECP, regardless of his/her status as a child with as disability, as that
               term is understood under Section 504, or the IDEA.

            I. The district shall ensure that the information contained in the IHCP (or other food
               allergy management plan) and ECP is distributed to any school personnel
               responsible for implementing any provisions of the IHCP and/or ECP. IHCP is
               reviewed with all personnel involved at the beginning of the school year and
               confidential written copies of essential information are provided to those with a
               “need to know” status.

            J. Whenever appropriate, a student with a life-threatening food allergy should be
               referred to a Section 504 Team for consideration if/when there is reason to believe
               that the student has a disability that substantially limits a major life activity, as
               defined by Section 504. Whenever appropriate, students with life-threatening
               food allergies should be referred to a PPT for consideration of eligibility for
               special education and related services if there is reason to suspect that the student
               has a qualifying disability and requires specialized instruction.




Rev. 9/06                                                                                          3
            K. When making eligibility determinations under Section 504 and/or the IDEA,
               schools must consider the student’s needs on an individualized, case-by-case
               basis.


III. Training

            A. The district shall provide appropriate education and training for school personnel
               including general awareness of life-threatening food allergies and appropriate
               child- specific information related to the management of students with life
               threatening food allergies as indicated in the IHCP. Such training shall include,
               as appropriate for each school and depending on the specific needs of the
               individual students at the school, administration of medication with cartridge
               injectors, i.e. Epi-pens, and preventative strategies to minimize a child’s risk of
               exposure to life-threatening allergens. Any such training regarding the
               administration of medication shall be done accordance with state law and Board
               policy.

               The school district will provide education and training to appropriate school
               personnel including, but not limited to, recognition of symptoms of anaphylaxis
               and knowledge of Emergency Care Plans. Custodians, cafeteria personnel,
               teachers, and support personnel will be provided training in sanitation and
               cleaning measures known to remove food proteins effectively. Farmington Public
               Schools transportation employees, i.e., van drivers for special education students
               and other small groups of students, are provided with education to respond to
               emergency situations, including recognizing signs of anaphylactic shock.
               Farmington Public School van driver employees carry a sealed confidential list of
               students with severe health concerns, including those identified as having life
               threatening food allergies. They are instructed not to open the envelope except in
               the event of emergency. Envelopes are returned to the transportation coordinator
               at the end of each school year.

               Drivers who are contracted by the school system to provide general student
               transportation do not have the same confidential lists on their busses. Instead,
               contracted bus service central dispatchers are provided with the list. Contracted
               bus service drivers are provided general safety training, not specific to allergies or
               health issues, eight times throughout the school year. In the event of emergency,
               contracted drivers are instructed to call 911 and to contact their dispatcher for
               additional information about the specific student’s condition and needs.

               Parents who have concerns about their child’s allergies or health care needs
               are strongly urged to provide all necessary and appropriate information to
               their child’s bus driver.




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IV. Prevention Measures

            A. Students and school personnel will be shown and encouraged to use effective
               hand-washing procedures with soap and water or hand wipes following eating to
               prevent cross-contact.

            B. Schools will consider and encourage ways to enforce safe practices among
               students, such as prohibiting food swapping or sharing, utensil sharing, and
               prohibiting eating on school transportation. Examples of ways to foster these
               expectations may include such activities as student-made posters in the cafeteria
               and reinforcement by teachers and cafeteria monitors.

            C. Parents who wish to obtain specific cafeteria food ingredients for food allergy or
               nutritional reasons should contact the district’s Food Services Director.

            D. School nurses will raise awareness of life-threatening food allergies in the school
               community through newsletter articles, bulletin boards, etc. Students will be
               provided child-specific information in accordance with a student’s IHCP.

            E. Where necessary, allergen-free zones will be created, e.g., lunch tables or a
               cafeteria zone, or classroom.

            F. Schools will consider options for creating food-free common areas, e.g., libraries,
               music and art rooms, publishing center etc. Considerations should include
               hanging posters in each food-free area designating it as such and providing flyers
               for parent volunteers related to the schools’ practices relative to food allergies and
               not eating or having food in food-free zones.

            G. School nurses will develop common practices for alerting and assigning substitute
               nurses. In addition, they will work with principals to develop common practices
               for alerting substitute teachers of the existence of an Individual Health Care Plan
               (IHCP), Emergency Care Plan (ECP) or 504 Plan.

            H. Teachers will be encouraged to plan celebrations (birthdays, holidays, etc.) that
               include alternatives to food, or to make provisions for allergen-free foods.

            I. Schools will plan for PTO/PTA sponsored events to include those with life-
               threatening food allergies.

            J. In some cases, schools may need to address issues related to accessing
               medications, allergy-free foods, etc. when planning for fire drills or secure
               building drills. Procedures relating to specific students will be articulated in their
               IHCPs.

            K. Schools will adhere to the Occupational Safety and Health Administration
               (OSHA) and Universal Precautions guidelines for disposal of epinephrine auto-
               injectors after use. To ensure student safety, only Epipens or other epinephrine
               auto-injectors may be used. Combination injectors such as the Twinject may not


Rev. 9/06                                                                                               5
               be used because the exposed needle of the second injection violates OSHA
               requirements. Further, this injection could not be administered by anyone other
               than a nurse.

            L. Farmington Public Schools van drivers are provided with cell phones for
               emergencies. Drivers are instructed to call 911 immediately in the event of an
               emergency, as well as to refer to the confidential health list with which they are
               provided.

            M. Contracted bus drivers, who transport students in standard school buses, are
               provided with two-way radios by their company for emergencies. Many of those
               drivers also have cell phones. Drivers are instructed to call 911 immediately in
               the event of emergency and to notify the dispatcher and request student health
               information.

            N. With written authorization from the child’s prescribing physician and with written
               parental permission, students may self-carry Epipens at all times in the original
               prescription box. This box must contain the student’s name, prescribing
               physician and dosage.




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V. Monitoring the District’s Plan and Procedures

     The district will conduct periodic assessments of its Food Allergy Management Plan and
     Procedures. Such assessments should occur at least annually and after any emergency
     event involving the administration of medication to determine the effectiveness of the
     process, why the incident occurred, what practices worked well and any adjustments that
     need to be put into place.


     Legal References:

            State Law/Regulations/Guidance

            Conn. Gen. Stat. § 10-212a Administration of Medications in Schools
            Conn. Gen. Stat. § 10-220i Transportation of students carrying cartridge injectors

            Conn. Gen. Stat.§ 19a-900    Use of cartridge injectors by staff members of
                                         before or after school program, day camp or day care
                                         facility.

            Conn. Gen. Stat. § 52-557b   “Good Samaritan law.” Immunity from liability for
                                         emergency, medical assistance, first aid or medication
                                         by injector. School personnel not required to
                                         administer or render.

            Regs. Conn. State Agencies § 10-212a-1 through 10-212a-7 Administration of
                                        Medication by School Personnel

     Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools,
     Connecticut State Department of Education (2006).

            Federal Law:

            Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794
            Individuals with Disabilities Education Act, 20 U.S.C. § 1400 et seq.
            The Americans with Disabilities Act of 1990 (ADA), 42 U.S.C. § 12101 et seq.
                                           441035 v.02




Rev. 9/06                                                                                         7
Dear Parent(s)/Guardian(s):

At        School we are committed to protecting the well-being of our students, especially those
with special health problems. This commitment includes assisting teachers, students, and
administrators to adapt to a student's health problems. Because of these goals it is important that
certain confidential information be shared by parents/guardians with those members of the
professional school staff who have direct responsibilities for the student with a health problem
when in school.

If your child has a chronic health problem or a health condition that may create a need for
emergency or supportive care during the school day please complete the attached form. As
school nurse, I am available to assist you in completing the form or to answer any questions that
you may have concerning the use of the information requested. Not all questions may apply to
your child's specific problem.

Upon receiving a completed and signed form I will contact the person who completed the form
to review or confirm the information before preparing an individualized emergency plan for the
student. When necessary I will provide in-service programs for teachers regarding the health
condition and the specific emergency procedures that may need to be initiated at school.

PLEASE REMEMBER to notify us during the school year of any changes in the child's health
status, medications, physicians, or any other information provided on the form so that the
emergency plan can be updated as needed. Your child's progress in school will be monitored and
reported to you on a regular basis. Parent-school communication is vital to the success of the
program.

We anticipate that this program will assist in providing a successful school experience for all
students with special needs or chronic health problems. Questions are welcomed and should be
directed to me at       .
                                                                         .
Sincerely,




School Nurse




Rev 7/06
                            FARMINGTON PUBLIC SCHOOLS
                         EMERGENCY AND HEALTH CARE PLANS

There are four (4) health care plans that are to be used by school nurses to provide information
about students. These HCPs provide necessary information for emergency situations, helps staff
know pertinent information and assists nursing staff obtain information to provide the optimum
physical, mental and emotional health and well being of each student.

    1. Emergency Referral Information should be completed and sent with the student when a
       student is going to the doctor or emergency room. A copy should he placed in the
       student's chart with a recorded summary of incident, emergency care given, vital signs
       and all pertinent medical history information.

    2. Individual Care Plans are necessary care plans to help nurse’s optimum support and care
       to individual students. HCP has a student database, plus documentation for assessment,
       management care and outcome. IHCP can be helpful in following students with asthma,
       seizure disorders, fractures, growth and development and multiple medical problems.
       Also, at-risk students, medically fragile students involving detailed medical data as well
       as suspected child abuse and/or emotional issues.

    3. Emergency Care Plans are designed to give information to teachers and staff to help
       them be aware of medical problems or concerns of their students including those with
       life-threatening allergies. These forms describe each medical condition, emergency
       warning signs and emergency action for a teacher to begin until the nurse arrives.

    4. Current Health Status and Emergency Care Plans for Students with Special Needs is a
       form to send to parents/guardians to obtain specific information for a student with special
       needs. Diagnosis, physician, medications and emergency procedure are include in the
       form. This enables the nurse to give the best care and have updated knowledge about a
       specific student. A letter accompanies this form and is sent to the parents or guardians.




Rev 7/06
                                                 FARMINGTON PUBLIC SCHOOLS
                                                INDIVIDUAL HEALTH CARE PLAN


 Student’s Name:                                                DOB:                           Effective Dates of Plan:

 School:                                       Grade:           Teacher:                             Doctor:

 Diagnosis:                                                         Medications:

 Medical History:


       ASSESSMENT             FUNCTIONAL HEALTH
                                                         STUDENT OBJECTIVES*            INTERVENTIONS*                EVALUATION*
       DATE/NURSE                 CONCERN*




* Refer to Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools for suggestions.




Rev 7/06                                                           over
      ASSESSMENT              FUNCTIONAL HEALTH
                                                          STUDENT OBJECTIVES*              INTERVENTIONS*    EVALUATION*
      DATE/NURSE                  CONCERN*




* Refer to Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools for suggestions.
School Nurse Signature:                           Date:                Parent Signature:                       Date:
Student Signature:                                Date:                 Other (opt.):                          Date:
IHCP meeting attendees:




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                                Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools

                                                 INDIVIDUALIZED HEALTH CARE PLAN

Name:                                                  Birth Date:                 Grade:                Teacher:




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Plan effective from                   to

 ASSESSMENT              FUNCTIONAL
                                                STUDENT OBJECTIVE(S)                    INTERVENTIONS                           EVALUATION
 DATE/NURSE           HEALTH CONCERN
                        Risk of anaphylactic       Student will cooperate        Parents will:                               Enter documentation
                        reaction (life-            with staff 100% of the        inform school nurse and teacher of food     method or date(s)
                        threatening allergic       time by following             allergy                                     accomplished for all
                        response) related to       school, classroom and         provide physician’s order and               applicable interventions
                        the ingestion or           IHCP rules in order to        medication for medical intervention
                        inhalation of peanuts      remain free of allergic       inform school nurse of any changes in
                        and/or tree nuts           reactions while in            health status as relates to food allergy
                        (protein component)        school.                       and treatment




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                                                                                 educate student in the self-management
                        Risk for life-             If student suspects that      of his/her food allergies appropriate for
                        threatening allergic       he/she has ingested           his/her age level
                        response to allergen;      (fill in food allergens),     provide emergency contact information.




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                        history of asthma          student will                  meet with school nurse, administrator
                                                   immediately notify            and teacher to develop a prevention
                        Risk of severe             staff who will                plan.
                        allergic reaction to       implement the IECP            provide safe snacks/treats for student to
                        the ingestion or           according to the              keep in school and, if desired, a list of
                        inhalation of (add         allergen-specific plan.       appropriate foods for student to have at
                        allergens here, as                                       snack.
                        applicable)                Student will cooperate        provide wipes for classmates to use
                                                   with staff members            entering room in am and after lunch.
                        Student has an             100% of the time if           inform school nurse and teacher of food
                        Individualized             they need to                  allergy prior to the start of school each
                        Emergency Care             implement the IECP.           year.
                        Plan (IECP)                                              provide a physician’s order and
                                                   Student will remain           medication for medical intervention,
                                                   free of allergic              both for Student to carry for self-
                                                   reactions to peanuts          administration and a back-up for the
                                                   while in school 100%          health office. Medication should not

Rev 7/06
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                                                                                                             Page 2 of 5
ASSESSMENT     FUNCTIONAL
                              STUDENT OBJECTIVE(S)                INTERVENTIONS                        EVALUATION
DATE/NURSE   HEALTH CONCERN
                                 of the time by            expire during the school year.
                                 following the IHCP        inform school nurse of any changes in
                                 requirements,             health status as relates to food allergy




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                                 especially food refusal   and treatment.
                                 and advocating for        educate Student in the self-management
                                 himself/herself when      of his/her food allergies appropriate for
                                 allergens may be          his/her age level.
                                 present in the            provide emergency contact information.
                                 environment.              meet with school nurse and teacher to
                                                           develop an IECP and IHCP.
                                 Student will              Nurse will:
                                 immediately initiate      meet with parents and teacher to
                                 self administration of    develop a prevention plan.
                                 emergency                 post “peanut/nut-free” sign outside of
                                 medications OR            classroom.




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                                 immediately notify an     work with teacher to eliminate the use
                                 adult and cooperate       of peanuts/tree nuts in classroom
                                 with staff                snacks, curriculum, educational tools,
                                 administration of         classroom parties, foreign language
                                 emergency                 projects, and arts and crafts projects.




                                                                                       E
                                 medications in the        educate school staff who interact with
                                 event of suspected        student regarding food allergy, allergic
                                 ingestion of peanut       reaction symptoms, recognizing signs
                                 100 % of the time.        and symptoms of anaphylaxis, and
                                                           prevention and treatment plans.
                                                           train school staff in EpiPen
                                                           administration, as appropriate.
                                                           develop and disseminate emergency
                                                           care plan for student
                                                           (add use of walkie-talkie if appropriate
                                                           and specific to student).
                                                           review cleaning/care of nut/peanut free
                                                           table in cafeteria with maintenance and
                                                           cafeteria staff.
                                                           meet with parents and teacher to
                                                           develop the IECP and IHCP.
                                                           work with teacher to eliminate the use
                                                           of allergen in classroom snacks,
                                                           curriculum, educational tools,
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                                                                                                      Page 3 of 5
ASSESSMENT     FUNCTIONAL
                              STUDENT OBJECTIVE(S)          INTERVENTIONS                       EVALUATION
DATE/NURSE   HEALTH CONCERN
                                                     classroom parties, foreign language
                                                     projects, and arts and crafts projects.
                                                     educate school staff who interact with




                          MP
                                                     Student regarding food allergy, and
                                                     recognition of symptoms of allergic
                                                     reactions, including local, general and
                                                     anaphylactic types, with emphasis on
                                                     recognition and emergency
                                                     interventions for the latter.
                                                     train certified personnel in EpiPen
                                                     administration, as appropriate.
                                                     develop and disseminate emergency
                                                     care plan and transportation plan for
                                                     student.
                                                     implement the IECP and direct




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                                                     emergency actions in the event of
                                                     anaphylaxis.
                                                     review with student, at least annually,
                                                     his/her knowledge of the symptoms of
                                                     anaphylaxis and skills needed for self




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                                                     administration of an EpiPen, including
                                                     practice in injecting an EpiPen into an
                                                     orange.
                                                     Teacher/classroom staff will:
                                                     eliminate the use of nuts/peanuts in
                                                     classroom snacks, educational tools,
                                                     and arts and crafts projects.
                                                     be trained in the administration of
                                                     EpiPen, as appropriate.
                                                     consult in advance of field trips with
                                                     the school nurse and parents.
                                                     [for food allergens other than
                                                     peanut/nut] notify parents in advance
                                                     regarding curriculum/projects that may
                                                     contain [add these food allergens].
                                                     Follow the emergency care plan if
                                                     Student has a reaction.
                                                     work to eliminate the use of allergen in
                                                     classroom snacks, curriculum,
SA
                                                                                                         Page 4 of 5
ASSESSMENT     FUNCTIONAL
                              STUDENT OBJECTIVE(S)           INTERVENTIONS                         EVALUATION
DATE/NURSE   HEALTH CONCERN
                                                     educational tools, classroom parties,
                                                     foreign language projects, and arts and
                                                     crafts projects.




                          MP
                                                     be trained in the administration of
                                                     EpiPen, as appropriate.
                                                     be prepared to implement the IECP if
                                                     indicated.
                                                     consult and collaborate in advance with
                                                     the school nurse and parents to decide
                                                     what accommodations are appropriate
                                                     for each field trip. Parents’ judgment
                                                     will be respected.
                                                     send to all parents the middle school
                                                     notice of field trip form which shall
                                                     contain a standard request that snacks




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                                                     and lunch be peanut/nut free.
                                                     notify parents in advance of in-class
                                                     food celebrations.
                                                     Student will:
                                                     not eat any foods except those that




                                                                                   E
                                                     come from home or have been
                                                     approved by the parent.
                                                     inform teacher/staff if he/she is not
                                                     feeling well, for any reason, but
                                                     especially of he/she thinks he/she may
                                                     be having an allergic reaction.
                                                     not eat any foods at school, on field
                                                     trips or in extracurricular activities that
                                                     do not come from home or have not
                                                     been approved by her parents.
                                                     inform teacher/staff if he/she is not
                                                     feeling well for any reason, but
                                                     especially of he/she thinks he/she may
                                                     be having an allergic reaction.
                                                     [For students carrying their own
                                                     medications] Follow the medication
                                                     plan for self-administration of EpiPen
                                                     and Benadryl. Accordingly, student
                                                     will bring to and from school, and at all
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                                                                                                        Page 5 of 5
ASSESSMENT     FUNCTIONAL
                              STUDENT OBJECTIVE(S)           INTERVENTIONS                        EVALUATION
DATE/NURSE   HEALTH CONCERN
                                                     times carry (e.g., in belt-carrying case
                                                     or in a purse) an up-to-date EpiPen and
                                                     dissolvable Benadryl tablet, according




                          MP
                                                     to the physician’s order. If a student
                                                     chooses to keep emergency medications
                                                     on his/her person, he/she will keep
                                                     them with him/her at all times in
                                                     school, during extracurricular activities,
                                                     and on field trips.
                                                     not self-administer Benadryl or EpiPen
                                                     without immediately notifying the
                                                     school nurse, or another responsible
                                                     adult, in the absence of the school
                                                     nurse.
                                                     not keep any medication in his/her




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                                                     locker.
                                                     participate with school nurse in review
                                                     of emergency self-administration of
                                                     medication plan and implementation
                                                     skills.




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                        FARMINGTON PUBLIC SCHOOLS
                           EMERGENCY CARE PLAN
                     FOR NON-ANAPHYLACTIC CONDITIONS

Name:                                          Date:
Address:                                   Birthdate:
Emergency Phone:                        Home Phone:
Doctor:                                 Doctor Phone:
School:                                        Grade:

Medical Conditions:




Treatment:




Emergency Signs:




Actions for Nurse:




Actions for Teacher/Secretary/Aide:




Rev 7/06
                               FARMINGTON PUBLIC SCHOOLS
                 CURRENT HEALTH STATUS AND INDIVIDUALIZED EMERGENCY PLAN
                             FOR STUDENTS WITH SPECIAL NEEDS

Student's Name                                                                       Sex               Date
Diagnosis, presenting problems or pertinent background:




Parent/Guardian:                                                Phone:
Physician's s Name:                                             Phone:
Address:
May we contact your primary care physician in the event of a concern or question?                        Yes     No
Does your child have allergies? Yes          No
      If yes, please provide details of allergy(ies):



Please outline a step by step emergency plan for your child for each health problem.
(If more space is needed please use reverse side.)

                        Problem                                   Your specific directions in the event of an emergency
                                                             1.
                                                             2.
                                                             3.
                                                             4.
                                                             5.
What medication is your child currently taking?
(If more space is needed please use reverse side.)

Medication Name                  Frequency           Medical Condition        Potential Side Effects    Prescribing Doctor




Are there any special precautions you would like the school to know regarding your child?

Is your child prone to experiencing any particular health problems on a regular basis?

Is there a special way your child behaves when he/she is ill or about to become ill?

Additional comments and/or explanations:




                                 Parent/Guardian Signature                                                Date

Rev 7/06
                                   FARMINGTON PUBLIC SCHOOLS
                               Medical Statement for Children with Disabilities
                                   Requiring Special Meals in Child Nutrition Programs

Part I (To be filled out by School)
Date:                               Name of Child:
School Attended by Child:

Part II (To be filled out by Medical Authority)
Patient's Name:                                                                                                    Age:
Diagnosis:

Describe the patient’s disability and the major life activity affected by the disability:



Does the disability restrict the individual’s diet?                                             Yes                   No

If yes, list food(s) to be omitted from the diet and food(s) to be substituted (Diet Plan):




List foods that require a change in texture:
Cut up or chopped to bite-size pieces:




Finely ground:




Pureed:




Special Equipment Needed:




Date:                                 Signature of Medical Authority:


The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, gender, age, or disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternate
means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202)
720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten
Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal
opportunity provider and employer.

Connecticut State Department of Education                                                                                        April 2004

Rev. 7/06                                             Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools
                                  FARMINGTON PUBLIC SCHOOLS
                            Medical Statement for Children without Disabilities
                                   Requiring Special Meals in Child Nutrition Programs

Part I (To be filled out by School)
Date:                               Name of Child:
School Attended by Child:

Part II (To be filled out by Medical Authority)
Patient's Name:                                                                                                    Age:
Diagnosis:

Describe the medical or other special dietary needs that restrict the child's diet:




List food(s) to be omitted from the diet and food(s) to be substituted (Diet Plan):




List foods that require a change in texture:
Cut up or chopped to bite-size pieces:




Finely ground:




Pureed:




Special Equipment Needed:




Date:                                 Signature of Medical Authority:


The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, gender, age, or disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternate
means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202)
720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten
Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal
opportunity provider and employer.

Connecticut State Department of Education                                                                                        April 2004

Rev. 7/06                                             Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools
                             FARMINGTON PUBLIC SCHOOLS
                          FOOD ALLERGY TREATMENT PLAN AND
        PERMISSION FOR THE ADMINISTRATION OF MEDICATIONS BY SCHOOL PERSONNEL


      PATIENT’S NAME:                                                          DATE OF BIRTH:
      PATIENT’S ADDRESS:                                                       TELEPHONE:
      CAAC PHYSICIAN’S NAME:                                                 PATIENT’S PCP:
      ASTHMA           YES      NO

      SPECIFIC FOOD ALLERGY:

      IF PATIENT INGESTS OR THINKS HE/SHE HAS INGESTED THE ABOVE NAMED FOOD:
          Observe patient for symptoms of anaphylaxis** X 2 hours
          Administer adrenaline before symptoms occur, IM                EpiPen Jr. Adult
          Administer adrenaline if symptoms occur, IM                    EpiPen Jr. Adult
          Administer Benadryl           tsp. or Atarax      tsp. Swish & Swallow
          Administer
          Call 911, transport to ER if symptoms occur for evaluation, treatment and observation X 4 hours


                                IF REACTION OCCURS, PLEASE NOTIFY THIS OFFICE!

      Physician’s Signature                                                            Today’s Date

                 1. Is this a controlled drug?     Yes      No Time of administration:
                 2. Medication shall be administered from                              to
                 3. Relevant side effects, if any, to be observed:
                 4. Other Suggestions: Please allow child to self-administer medication if able to.



**SYMPTOMS OF ANAPHYLAXIS                                         Signature                      , M.D.
Chest tightness, cough, shortness of breath, wheezing            I HAVE RECEIVED, REVIEWED, AND
Tightness in throat, difficulty swallowing, hoarseness           UNDERSTAND THE ABOVE INFORMATION
Swelling of lips, tongue, throat
Itching mouth, itchy skin
Hives or swelling
Stomach cramps, vomiting, or diarrhea                            Patient/parent/guardian signature
Dizziness or faintness

                                                 Date/Initials

                                                                 CAAC/DMC Food Allergy Treatment Plan 01/05




      Rev 7/06                                                   Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools
                        FARMINGTON PUBLIC SCHOOLS
                    Risk Assessment Questions School Nurse Asks
                      Coordinator of the Field Trip Destination
                                    Grades K-4

Field Trip Destination:
Child’s Name:
Child’s Allergy(ies):



Child’s Sensitivity:   Contact/Ingestion         Cooking vapors
Teacher in charge:
Field trip date:                                     Field trip time:
Destination Contact Person:
            Name:
            Telephone Number:
            Date of Conversation:
Date of Telephone Conversation with Parent:
Child’s Parent Attending:    Yes         No
Nurse Attending:      Yes         No

Questions:
  1. Will anyone at the field trip destination be distributing any food or beverage of
      any type and what is it?
  2. Will the children on the field trip be touching any type of food and what is it?
  3. Is there any food displayed at the site and what is it?
  4. Is there any food used in any of demonstrations or as feed for any animals that the
      children can buy or are given and what is it?
  5. Are there any hand-on activities that involve food and what is it?
  6. Which trained adult will proctor the child with food allergy while s/he is washing
      his/her hands with soap and water before snack./lunch? Will the child bring
      his/her own soap?
  7. How will snack/lunches be stored on the bus ride to the field trip destination?
  8. Which adult will be responsible for storing and distributing the children’s
      snack/lunches?
  9. Where will children eat snack?
  10. Where will children eat lunch?
  11. Where will students use wipes after snack/lunch?
  12. Are the tables where the children eat able to be adequately washed with soap and
      water (and by whom) or do they need plastic table cloths?
  13. Which trained adult will be in charge of the child’s snack/lunch who has food
      allergy?
  14. What steps will be taken to keep the child’s lunch/snack separate from others?
  15. Which person will distribute the child’s snack/lunch?
  16. Which person will check to be sure that he offending allergen is not given to the
      child?

Rev. 7/06                                   Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools
17. Will the teacher in charge discuss with all attending adults, teachers and parent
    chaperones, that under no circumstances is the child to be allowed to eat or touch
    or given any food or drink by any other adults? The child must only eat/drink
    food that has been provided by the parent and distributed to the child by the
    teacher/nurse in charge.
18. Will it be discussed that the EpiPen Jr. must be with the child on all fieldtrips,
    both long and short?
19. Who will be responsible for carrying and administering the medications in an
    emergency situation?
20. Will medications, authorizations and emergency care plans be routinely sent with
    classroom teachers for all medically involved students when leaving the school
    grounds for any reason, including brief walks and hikes?
21. Do the parents always want the child’s regular classroom teacher to be his or her
    proctor on a field trip?
22. Do the parents want the child’s regular classroom teacher or school nurse to carry
    the Medicine Pack?
23. Do the parents want to be able to accompany the child on a field trip, but not be
    responsible for a whole group of children?
24. Will all teachers and adults responsible for children on the field trip review the
    Emergency Response Protocol prior to the field trip?
25. Will the teacher in charge privately remind parent chaperones of the child’s food
    allergy, and to be sure not to give him any food?
26. Since different adults will be involved with each field trip, will the teacher in
    charge create a list of trained adults who can administer the EpiPen Jr.? (Ex. #1
    Nurse's Name, #2 Teacher's Name, #3 Teacher's Name)
27. Will the school nurse not be given a group of children to proctor, but travel with
    the regular classroom teacher?
28. Will the nurse map out a route to the nearest hospital from the field trip
    destination and give it to the classroom teacher the before the day of the field trip?
29. Will this emergency driving route be given to the bus driver?
30. How would the teacher contact 911?
31. What steps will be taken if 911 (no cell phone connection) cannot be reached in
    the event of an emergency after the child has received the EpiPen Jr.?
32. Will the nurse/teacher carrying the medicine pack carry a charged cell phone?
                           FARMINGTON PUBLIC SCHOOLS
                       Risk Assessment Questions School Nurse Asks
                         Coordinator of the Field Trip Destination
                                       Grades 5-12

Field Trip Destination:
Child’s Name:
Child’s Allergy(ies):



Child’s Sensitivity:   Contact/Ingestion                Cooking vapors
Teacher in charge:
Field trip date:                                            Field trip time:
Destination Contact Person:
            Name:
            Telephone Number:
            Date of Conversation:
Date of Telephone Conversation with Parent:
Child’s Parent Attending:    Yes         No
Nurse Attending:      Yes         No
Questions:
     1. Will anyone at the field trip destination be distributing any food or beverage of any type
         and what is it?
     2. Will the children on the field trip be touching any type of food and what is it?
     3. Are there any hands-on activities that involve food and what is it; e.g. animals, feed, etc.?
     4. What measures will be taken by the adult who will be responsible for storing and
         distributing the student’s snack/lunches to prevent cross-contamination of food that will
         be consumed by students with food allergies?
     5. Will the tables where the students eat be adequately washed with soap and water (and by
         whom) or will table cover be needed?
     6. If students will be consuming food that is not sent from home, who will check to be sure
         that the offending allergen is not given to the child?
     7. In area where students will be consuming/handling food, what measures will be taken to
         prevent accidental exposure; e.g. tables, others’ food, etc.?
     8. Who will be responsible for discussing with all attending adults, teachers and parent
         chaperones that under no circumstances is the student to be given any food or drink other
         than their own by another person? The child must only eat/drink food that has been
         provided by the parent and distributed to the child by the teacher/nurse in charge.
     9. Will it be discussed that the EpiPen must be with the child on all fieldtrips, both long and
         short?
     10. Who will be responsible for carrying and administering the medications in an emergency
         situation?
     11. Will medications, authorizations and emergency care plans be routinely sent with
         classroom teachers for all medically involved students when leaving the school grounds
         for any reason?
     12. Who will carry a copy of the Emergency Response Protocol and Medication
         Authorization Form for students with Food Allergies?
     13. What steps will be taken if 911 (no cell phone connection) cannot be reached in the event
         of an emergency after the child has received the EpiPen?
     14. Will the nurse/teacher carrying the medicine pack carry a charged cell phone to place
         emergency calls?
Rev. 7/06                                          Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools
                                   FARMINGTON PUBLIC SCHOOLS
                                     Emergency Response Protocol
                                      Severe Food Allergy to

Student’s Name:
Teachers:
Parent Contact:     Mother Name:                                Home Phone:
                     Cell Phone:                              Work Phone:
                    Father Name:                                Home Phone:
                     Cell Phone:                              Work Phone:
Doctor Name:                                                  Doctor Phone:

Key safety rules:


Asthmatic and at increased risk for severe reaction    Yes          No

SIGNS OF AN ALLERGIC REACTION INCLUDE:




Medicine Location Kit:


What to do:




Rev. 7/06                                             Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools
                                   FARMINGTON PUBLIC SCHOOLS
                                     Emergency Response Protocol
                                     Severe Food Allergy to Peanuts
Student’s Name:
Teachers:
Parent Contact:     Mother Name:                                  Home Phone:
                    Cell Phone:                                   Work Phone:




SA
                    Father Name:                                  Home Phone:
                    Cell Phone:                                   Work Phone:
Doctor Name:                                                   Doctor Phone:
Key safety rules of the classroom and outside play area:
   • The regular and specials classrooms and play-areas are peanut- and tree nut-free environments
   • The child will travel with their Epipen® medicine kit and a walkie-talkie will remain with the child at
       all times during the day and be managed by a trained adult.




                            MP
   • The child eats only foods provided and labeled by the parent/guardian. Adult will assist the child daily
       in washing his/her hands thoroughly with soap and water for 15 seconds before eating. Adult in charge
       will approve daily snacks and other foods consumed by students.
   • Students and adults should wipe their hands upon entering the classroom and practice good hand
       washing techniques after eating.
   • If the child asks to see the nurse, allow him/her to do so immediately with an adult for any reason
Asthmatic and at increased risk for severe reaction    Yes         No




                                                                        LE
Rev 7/06                                              Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools
                           FARMINGTON PUBLIC SCHOOLS
                   HEALTH SERVICES SELF-MEDICATION ASSESSMENT

Student:                                               School:
D.O.B.:                                  Age:                                     Grade:
Physical/behavioral limitations:

Name of medication:

Self-Medication Criteria:
   Yes     No A. Student is capable of identifying individual medication.
Comments:

  Yes     No       B. Student is knowledgeable of purpose of individual medication.
Comments:

                   C. Student is able to identify/associate specific symptom occurrence and
  Yes     No          need for medication administration.
Comments:

  Yes     No       D. Student is capable/knowledgeable of medication dosage.
Comments:

  Yes     No       E. Student is knowledgeable about method of medication administration.
Comments:

  Yes     No       F. Student is able to state side effects/adverse reactions to medication.
Comments:

                   G. Student is knowledgeable of how to access assistance for self if needed
  Yes     No         in an emergency.
Comments:

                   H. An individual Health Care Plan has been developed for the student that
  Yes     No         will monitor and evaluate the student's health status.
Comments:


Based on assessment:
    The student is not a candidate for a self-medication program at this time.
    The student is a candidate for a self-medication program with supervision.
    The student has successfully completed self-medication training and has demonstrated
    appropriate self-administration.
Comments:
Principal/Teacher notified?     Yes      No
Nurse Signature:                                                                 Date:


Rev. 7/06                                     Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools

								
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