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Obamagreencharterhigh.sharpschool.net

Green Brook Family Medicine
Ronald M. Frank, M.D. FAAFP
Sean M. Cook, M.D.
Jennifer E. Wiseman, APN-C
ADMINISTRATION OF EPI-PEN (EPINEPHRINE) AT SCHOOL
Dear Parent /Guardian: New Jersey P.L. 2007, c57. And N.J.S.A. 18A:40-12.3-12.6 allows trained delegates for students who may require emergency administration of epinephrine by auto-injector for anaphylaxis when the school nurse is unavailable. The 2 attached forms are required for your child to receive epinephrine by auto-injector. The first form gives the school district permission to allow for the school nurse and trained employees of the school district to administer epinephrine via auto-injector when the school nurse is not physically present at the scene. It is in your child’s best interest to at least have this form completed and returned to school as soon as possible. The second form allows your child to carry and self-administer epinephrine by auto-injector and diphenhydramine. Please understand that this request may not be appropriate for your child. I urge you to discuss this with your medical provider and return this form if appropriate. If you have any questions regarding these forms please do not hesitate to contact the School Nurse. Sincerely, Ronald M Frank, MD FAAFP School Medical Inspector SCHOOL NURSE AND DELEGATE
ADMINISTRATION OF EPINEPHRINE AT SCHOOL
Student Name: ___________________________ {CHILD’S PHOTO}

RECOMMENDATIONS ARE EFFECTIVE FOR ONE (1) SCHOOL YEAR ONLY

AND MUST BE RENEWED ANNUALLY

I. Parental/Guardian Consent for School Nurse and Delegate Administration
:
I hereby acknowledge my understanding that if the procedures outlines in P.L. 2007, c.57 and “TRAINING
PROTOCOLS FOR THE EMERGENCY ADMINISTRATION OF EPINEPHRINE “ issued by the NJ Department of
Education are followed, the school district and its employees or agents shall incur no liability as a result of any injury
arising from the administration of a pre-filled single dose auto injector containing epinephrine and the parent/guardian
shall indemnify and hold harmless the school district and its employees or agents against any claims arising from the
administration of a pre-filled single dose auto injector containing epinephrine to the student.
The school nurse shall have primary responsibility for administration of the auto-injectable epinephrine. The school
nurse shall designate, in consultation with the Board of Education, additional employees of the school district to
administer epinephrine via auto-injector to my child for anaphylaxis or possible anaphylaxis when the school nurse is
not physically presents at the scene, as specified in P.L. 2007, c.57.
____ I approve having delegate(s) assigned for my child. I understand that a list of my student’s delegates is
available for review in the nurse’s office.
____ I refuse to have a delegate for my child.
Parent/Guardian’s Name: _____________________________________________________
Parent/Guardian’s Signature: __________________________________Date:____________
II. Healthcare Provider’s Order:
The above student has a potentially life threatening allergy that could result in anaphylaxis. This student requires the
administration of epinephrine by pre-filled single-dose auto-injector and (Diphenhydramine if ordered) in the event of
anaphylaxis or possible anaphylaxis.
The Student’s potential triggers of Anaphylaxis are: ___________________________________________
____________________________________________________________________________________
The Student is an Asthmatic _________Yes __________No
The Student’s possible symptoms of Anaphylaxis are: _________________________________________
____________________________________________________________________________________
Or __________possible symptoms are unknown at this time but student is at risk for future anaphylaxis.
Please administer ______EpiPen® 0.3mg ________EpiPenJr® 0.15mg
_________ If medically necessary administer a second dose of epinephrine
If the school nurse is available administer: Oral Diphenhydramine Dose: ___________________
Physician’s Name
Physician’s Signature

Physician’s Office Stamp:
STUDENT AUTHORIZATION FOR SELF ADMINISTRATION OF
EPINEPHRINE AUTOINJECTOR AND ANTIHISTAMINE
N.J.S.A. Title 18A:40-12.3 directs that students may be permitted to self administer medications for asthma or other potentially life-threatening illnesses provided proper procedures are followed. RECOMMENDATIONS ARE EFFECTIVE FOR ONE (1) SCHOOL YEAR ONLY
AND MUST BE RENEWED ANNUALLY

The following section is to be completed by the PARENT/GUARDIAN:

Student’s Name
I request that my child be ALLOWED to carry the prescribed medication for self-administration in school and on off-site school related activities pursuant to N.J.A.C:.6A:16-2.3. I give permission for my child to self-administer medication, as prescribed on this form for the current school year as I consider him/her to be responsible and capable of transporting, storing and self-administration of the medication. I understand that the school district, agents and its employees shall incur no liability as a result of any condition or injury arising from the self-administration by the student of the medication prescribed on this form. I indemnify and hold harmless the School District, its agents and employees against any claims arising out of self-administration or lack of administration of this medication by the student. Parent/Guardian Signature

The following section is to be completed by the MEDICAL PROVIDER:

The above student has a potentially life threatening allergy that could result in anaphylaxis. This pupil requires the
administration of epinephrine by pre-filled single-dose auto-injector and (Diphenhydramine if ordered) in the event of
anaphylaxis or possible anaphylaxis.
Name of medication:
______EpiPen® 0.3mg ________EpiPenJr® 0.15mg
______If medically necessary administer a second dose of epinephrine
______Diphenhydramine Oral Dose: ___________________ x 1 time.
I verify that the child above requires this medication and
a. This student has been instructed in and is capable of proper method of self-administration of the medication prescribed above.
b. This student understands the purpose, appropriate method and frequency of use of the medication prescribed above.
c. The student’s medication, if ingested by someone other than the student will not cause severe illness or death.
Physician’s Name
Physician’s Office Stamp: Approved By School Nurse: ______________________________________ _________________ Signature Approved By School MD: _______________________________________ _________________

Source: http://obamagreencharterhigh.sharpschool.net/UserFiles/Servers/Server_38669/File/Nurse%20Forms/6EpiPenpacketbringtoMD.pdf

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