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PISCATAWAY TOWNSHIP SCHOOLS 5205 Ludlow

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					                                                                             5205 Ludlow Street
                                                                        Piscataway, NJ 08855-1332
                                                                            732 699-1563 x5465
                                                                              Fax 732 844-9407
                                                                        www.piscatawayschools.org
        Robert L. Copeland
     Superintendent of Schools

     Deborah I. Dawson, Psy.D.
   Coordinator of Health Services

Dear Parents/Guardians:

Anaphylaxis is a rapid (most often), severe allergic response that occurs when a person is
exposed to an allergen, an allergy-causing substance, to which he or she has been previously
sensitized. It is brought on when the allergen enters the blood stream causing the release of
chemicals throughout the body that try to protect it from the foreign substance. This response
can be a life-threatening event. The skin, respiratory, cardio-vascular, and gastro-intestinal
systems are most commonly involved.

Signs and symptoms can include hives or rash, swelling of the face and/or extremities, tingling
of the lips and mouth, flushing of the face or body, coughing, wheezing, shortness of breath,
nausea, vomiting, abdominal cramps, diarrhea, increased heart rate, low blood pressure, and
fainting.

Common triggers for anaphylaxis are stings of bees, wasps, hornets, yellow jackets, and fire ants;
foods including peanuts and other nuts, milk, eggs, shellfish, whitefish, as well as some food
additives; medication including certain antibiotics, anticonvulsants, muscle relaxants, aspirin,
and non-steroidal anti-inflammatory agents; latex; and exposure to certain chemical agents such
as cedar chips, herbicides and pesticides. Exercise, particularly after eating, can also cause an
anaphylactic reaction.

It is very important that if your child has had an anaphylactic reaction in the past and
must maintain his/her own EpiPen, please notify me at________________________.
Working together we will have procedures in place to provide emergency treatment for
your child should an anaphylactic reaction occur at school.

Sincerely,



Health Services
                                                                              5205 Ludlow Street
                                                                         Piscataway, NJ 08855-1332
                                                                             732 699-1563 x5465
                                                                               Fax 732 844-9407
                                                                         www.piscatawayschools.org
        Robert L. Copeland
     Superintendent of Schools

     Deborah I. Dawson, Psy.D.
   Coordinator of Health Services

EMERGENCY ADMINISTRATION OF EPINEPHRINE - PARENT/GUARDIAN REQUEST



I am requesting that my child,______________________________________________________

Receive _____________________________________________________________Medication

         _____________________________________________________________Dose

for Anaphylaxis as Prescribed by___________________________________________________
                                              Healthcare Provider

This medication is to be administered when my child is exposed to ________________________

______________________________________________________________________________

__________________________________and does not have the capacity for self administration.

In addition to this request/authorization, I am submitting:
        1. The written orders from my child’s healthcare provider
        2. A current, pre-filled single dose auto-injector mechanism containing epinephrine
                (EpiPen)

I understand that this request/authorization is effective for the school year in which it is granted
and must be renewed each subsequent school year.

I have received written information regarding the emergency administration of epinephrine via
EpiPen and the district shall have no liability as a result of any injury arising from the
administration of the EpiPen to my child.

I understand the district’s policy and regulations regarding the emergency administration of
epinephrine and will hold harmless the district and its employees or agents against any claims
arising out of the administration of the EpiPen to my child.


_________________________________                 _______________________________________
Signature of Parent/Guardian                      Print Name

_________________________________
Date
                                                                                                11/10
                                                                                        5205 Ludlow Street
                                                                                   Piscataway, NJ 08855-1332
                                                                                       732 699-1563 x5465
                                                                                         Fax 732 844-9407
                                                                                   www.piscatawayschools.org
         Robert L. Copeland
      Superintendent of Schools

     Deborah I. Dawson, Psy.D.
   Coordinator of Health Services
                           INDIVIDUAL EMERGENCY HEALTH CARE PLAN

Pupil’s Name_______________________________________ Date of Birth________________________

ID#_______________________________________________ Grade_____________________________

Specific Allergen(s) and Signs of Pupil’s Allergic Reaction Include:___________________________

____________________________________________________________________________________

____________________________________________________________________________________

Symptoms of Anaphylaxis Reaction:
Mouth        itching and swelling of the lips, tongue or mouth
Throat       itching and/or sense of tightness in the throat, hoarseness and/or hacking cough
Skin         hives, itchy rash and/or swelling about the face or extremities
Abdomen      nausea, abdominal cramps, vomiting and/or diarrhea
Lungs        shortness of breath, repetitive coughing and/or wheezing
Heart        “thready” pulse, syncope/fainting

Note: If anaphylaxis is the result of insect sting(s) and stinger(s) is(are) present, scrape or flick it(them)
with fingernail, plastic card, etc. Do Not squeeze or pinch with tweezers as this will inject more venom.

Action if Exposure Occurs:
        1. Observe Signs and Symptoms
        2. Give Medication as Prescribed
        3. Call 911 and Activate Emergency Medical Services
        4. Repeat EpiPen Yes____ No____ Reason________________________________________
        5. Emergency Contacts (Please Print)

                 #1____________________________ _________________ _____________________
                        Name                       Phone/Cell          Relationship

                 #2____________________________ _________________ _____________________
                        Name                       Phone/Cell          Relationship

                 #3____________________________ _________________ _____________________
                        Name                       Phone/Cell          Relationship

        6. Healthcare Provider_______________________________ Phone_______________________

        7. Preferred hospital_____________________________________________________________

___________________________                ________________________          __________________________
Signature of Parent/Guardian                      Delegate                          Delegate

_______________________________________ _____________________
Nurse                                   Date
_______________________________________ _____________________
Reviewed by School Medical Inspector    Date                                                              10/10
                                                                             5205 Ludlow Street
                                                                        Piscataway, NJ 08855-1332
                                                                            732 699-1563 x5465
                                                                              Fax 732 844-9407
                                                                        www.piscatawayschools.org
        Robert L. Copeland
     Superintendent of Schools

    Deborah I. Dawson, Psy.D.
  Coordinator of Health Services

 EMERGENCY ADMINISTRATION OF EPINEPHRINE - HEALTHCARE PROVIDER REQUEST

To Maintain/Protect the Health of _________________________________________________
the Emergency Administration of Epinephrine for Anaphylaxis is Required.

_______Please initial if pupil may carry Epinephrine during the school day. A request for
Epinephrine to be carried insures that the pupil has received instruction in the proper use
of Epinephrine.

In the event that ____________________________________does not have the capacity for self-
administration, the nurse or designee(s), delegated and trained by the nurse, will administer the
medication.

Medication:____________________________________________________________________

Dosage:_______________________________________________________________________

When to be Administered:________________________________________________________

In the event of _____________________________________________________________,

Repeat Medication as ordered above No_____ Yes_____*

*If a repeat dose is recommended, two pre-filled, single dose auto-injector mechanisms
containing epinephrine will be needed at school.

Purpose of the Medication:________________________________________________________

Possible Side Effects:____________________________________________________________

______________________________________________________________________________

Diagnosis/Specific Allergy(ies):____________________________________________________

______________________________________________________________________________

Comments/Specific Recommendations:______________________________________________

______________________________________________________________________________


_______________________________________
Signature of Healthcare Provider
                                                            Healthcare Provider Stamp
__________________________
Date
*REQUESTS ARE EFFECTIVE FOR ONE SCHOOL YEAR ONLY AND MUST BE RENEWED
                              ANNUALLY*
                                                                                              10/10
                       Policy - Emergency Administration of Epinephrine


Purpose:
The Board of Education recognizes that pupils attending Piscataway schools may suffer from a
severe, life threatening allergic reaction called anaphylaxis. Pupils with a history of anaphylaxis
(as documented by a physician or advanced practice nurse) may require the emergency
administration of epinephrine for anaphylaxis and do not have the capability for self-
administration of the medication.

Basic Policy:
A nurse may not be immediately available to assess the severity of an allergic reaction and to
administer epinephrine for pupils who cannot administer the medication themselves. Therefore,
the nurse, in consultation with the board of education, may designate another employee of the
school district to administer epinephrine via an auto-injector (EpiPen) to a pupil for anaphylaxis.

The parent/guardian of the pupil will provide to the board of education written authorization for
the administration of a pre-filled, single dose auto-injector mechanism containing epinephrine
(EpiPen); written orders from the healthcare provider that the pupil requires the administration of
epinephrine for anaphylaxis and may not have the capability for self-administration of the
medication; and a pre-filled, single dose auto-injector mechanism containing epinephrine
(EpiPen) and its replacement as necessary.

The board of education will inform parents/guardians of the policy and regulations regarding
emergency administration of epinephrine via EpiPen. As long as the parents/guardians are so
informed in writing, the district shall have no liability as a result of any injury arising from the
administration of the EpiPen to the pupil.

The parents/guardians by signing a statement acknowledging their understanding of the policy
and regulations shall indemnify and hold harmless the district and its employees or agents
against any claims arising out of the administration of the EpiPen to the pupil.

The parental/guardian permission is effective for the school year for which it is granted and is
renewed for each subsequent school year upon fulfillment of the requirements.

Nursing Services will establish criteria for choosing an appropriate employee and provide
training according to the “Protocol and Implementation Plan for the Emergency Administration
of Epinephrine by a Delegate Trained by the School Nurse” (developed by the Department of
Education and the Department of Health and Senior Services) and develop appropriate forms for
documentation.

Resource:
P.L. 1997,c.368(N.J.S.A.18A:40-12.5-12.6)

				
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