Westex.org

WEST ESSEX REGIONAL SCHOOLS
Part 1: To be completed by Physician
Student’s Name:_____________________________________ D.O.B._____________ Grade (in September)_____
ALLERGY TO:________________________________________________________________________________

Medical Diagnosis (CIRCLE)
Asthmatic: Yes * No (*Higher risk for severe reaction)
STEP 1: TREATMENT
Symptoms:
Give Checked Medication
* If a food allergen has been ingested, but no * Mouth Itching, tingling, or swelling of lips, tongue, mouth * Skin Hives, itchy rash, swelling of the face or extremities * Gut Nausea, abdominal cramps, vomiting, diarrhea * Throat:^ Tightening of throat, hoarseness, hacking cough
* Lung:^ Shortness of breath, repetitive coughing, wheezing
* Heart:^ Thready pulse, low blood pressure, fainting, pale, blueness
* Other ____________________________________________ * If reaction is progressing (several of the above areas affected), give The severity of symptoms can quickly change. ^Potentially life-threatening
DOSAGE:
Epinephrine: inject intramuscularly (circle one):
Epi-pen

Antihistamine: give ___________________________________________________________________
Check all that apply:
_____ Student has been trained in procedure and may carry and self-administer Epi-Pen
_____ Student has been instructed in symptom recognition, is capable of, and may self-administer
Benadryl according to N.J.S.A. 18A:40-12.3
_____ Student may self-administer (circle one) with or without adult supervision.
_____ Benadryl may be omitted from the above plan on a field trip in the absence of an authorized
Licensed staff member and when student is not capable of self administering this. (Parent has
option of accompanying child and administering this on field trip)
STEP 2: EMERGENCY CALLS
1. Call 911 (requesting paramedics). State that an allergic reaction has been treated, and additional epinephrine
2. Call Dr. ________________________________at ___________________________________
3. Call Emergency contacts as listed on reverse side.
____________________________________________________________________________________
If Parent/Caregiver cannot be reached, do not hesitate to medicate or take child to medical facility.

Parent/Caregiver Signature:______________________________________Date:______________________

Doctor’s Signature:______________________________________________Date:______________________
WEST ESSEX REGIONAL SCHOOLS

PART 2: To be completed by Parent/Guardian
Emergency Contacts:
Name/Relationship Phone Number(s):
a.______________________________________1.____________________2._______________________
b.______________________________________1.____________________2._______________________
c.______________________________________1.____________________2._______________________
A. Parent/Guardian Permission for School Nurse Administration of Medication
To be completed by Parent/Caregiver: I give my permission for the school nurse to administer the medication described on
the reverse side. I will notify the nurse immediately if this medication is no longer required.
I disclaim all liability of the West Essex Board of Education as it concerns the use of this medication.
I further understand that this permission is effective for the school year for which it is granted and must be renewed for
each subsequent school year upon fulfillment of requirements set by the board.
_____________________________________________ _________________________
Parent/Caregiver Signature Date
B. Parent/Guardian Permission for Self-Administration of Epi-Pen and/or Benadryl
To be completed by Parent/Caregiver: I give my permission for my child to self-administer the medication as described on
the reverse side. I will notify the school nurse immediately if this medication is no longer directed by the physician.
I understand and agree that the district shall incur no liability as a result of any injury arising from the self-administration of
medication by the pupil and that I shall indemnify and hold harmless the district and its employees or agents against any claims
arising out of the self administration of medication by the pupil.
I further understand that this permission is effective for the school year for which it is granted and must be renewed for
each subsequent school year upon fulfillment of requirements set by the board.
____________________________________________ __________________________
Parent/Guardian Signature Date
C. Student Agreement for Self-Administration
To be completed by the student: I understand that I will use this medication as directed by my physician. I will be responsible
and discreet using the medication as described on the reverse side and should have this medication readily accessible. I have
been instructed how to self-administer this medication and understand the side effects of improper use. The medication must be
carried in the original labeled pharmacy container.
I understand that if I do not abide by these regulations, I may forfeit my right to carry and self-administer this
medication. I disclaim all liability of the West Essex Board of Education as it concerns my use of this medication.
___________________________________________ ___________________________
Student’s Signature Date
D.Treatment by Delegate When Nurse Not Present  
NJ State Assembly Act Senate No. 79 directs that the school nurse shall designate additional employees of the school district
who volunteer to administer a one time dose of epinephrine to a pupil for anaphylaxis when the nurse is not physically present
at the scene. I give my permission for a delegate to be assigned to my child in the event a nurse, or myself are not present. I
disclaim all liability of the West Essex Board of Education and its employees as it concerns the use of this medication.
____________________________________________ __________________________
Parent/Guardian

Source: http://www.westex.org/cms/lib6/NJ01001533/Centricity/Domain/36/nurse_forms/life-threatening-allergy-action.pdf