35
GUIDELINES FOR CHILDREN AT RISK FOR ANAPHYLAXIS RELATED TO FOOD ALLERGY
GUIDELINES FOR CHILDREN AT RISK FOR
ANAPHYLAXIS RELATED TO FOOD ALLERGY
HEALTH SERVICES 2017
ORGANIZATION
The campus Registered Nurse is the point of contact for management of students at risk for anaphylaxis and works in collaboration with the Campus Allergy Management Team to reduce risk for students subject to potential anaphylaxis. In addition to the Registered Nurse, members of the Campus Allergy Management Team may include:
o Campus Administration
o Classroom Teacher
o School Counselor
o Food Service Manager
o Nutrition and Food Services Department
o Lead Custodian
o Transportation Representative
HEALTH SERVICES 2017
ASSESSMENT AND PLANNING
• Information regarding student food allergy will be elicited at the time of enrollment via Request for Food Allergy Information form. Parent reports of allergy that are not diagnostically confirmed by a licensed medical provider will be noted in the student health record by the school registered nurse and housed in the student cumulative folder.
o When provided with a completed Special Dietary Accommodation form, Klein ISD Nutrition & Food Services will record the food allergy special instructions in their electronic record.
o The School Nurse will inform the parent that food substitutions cannot be made based solely on the Request for Food Allergy Form.
• For a diagnosed food allergy, the parent will provide an updated Allergy Action Plan (AAP) prior to the start of the school year. The AAP should include:
o The name, date of birth, and grade level of the child. o A picture of the child so that they can be easily identified. o A list of the foods to which the child is allergic. o Indication of whether or not the child has asthma (higher risk for severe reaction if the
child has asthma). o Clear instructions on what symptoms require the use of epinephrine immediately. o Clear instructions (including diagrams) on how epinephrine should be administered. o The name of medications to be utilized in an emergency including either the brand name,
or the generic name and the dosage to be administered, and when to give an additional dose of emergency medications.
o Instructions regarding monitoring the child and communicating to EMS the medications that were given, what time the medications were given and how to position the child when they have had a severe reaction.
o Dated signatures by the parent, the licensed medical provider. o A place to list contact information for parents/guardians, healthcare providers and other
emergency contact information including phone numbers. • The campus Registered Nurse, in collaboration with the parent, will utilize the AAP to develop an
Individualized Health Care Plan (IHP) for the student which documents day to day management and emergency care of the student’s food allergy. A sample IHP can be located on pages 19 – 21 of this guideline. Whenever possible, this planning should take place prior to the beginning of the school year.
o The IHP for food allergy students should take into consideration the need to assign an adult to monitor safe food selections.
o The Klein ISD Special Dietary Accommodation form must be completed for those students requiring food substitution. The AAP cannot be substituted for this form.
o Consideration should be given to planning for school sponsored extracurricular activities and before/ after school events.
HEALTH SERVICES 2017
o Consideration should be given to a Section 504 plan for the student. o The school nurse will have two weeks’ advance notice of field trips so appropriate plans
can be made for food, training, and medication administration. • Epinephrine should be stored in a secure but unlocked area.
HEALTH SERVICES 2017
TRAINING AND INTERVENTION
• Compliance training for all school staff on allergy awareness. • The School Nurse will provide a paper or electronic copy of the AAP/IHP/Emergency Action Plan
(EAP) to Transportation, Food Service, and Classroom Staff. School Administration, Counseling and custodial staff will receive verbal instructions and may request a hard copy for their records. All are advised of the central location for the AAP/IHP/EAP.
o All above are trained on allergy awareness, signs and symptoms of an anaphylactic reaction, and intervention to include administration of epinephrine auto injector.
o All above are advised regarding location of the student’s epinephrine auto injector. o Auxiliary/substitute bus drivers will be trained on allergy awareness, signs and
symptoms of an anaphylactic reaction, and intervention to include administration of epinephrine auto injector.
o Classroom teachers will make severe allergy information available for substitute teachers and advise them to meet with the School Nurse for student specific training.
o Nutrition & Food Service personnel are trained in avoiding cross contamination during food preparation.
o Nutrition & Food Service personnel are not solely responsible for safe food selections by students.
• All students/staff wash hands before and after lunch and before returning to the class from recess, using running water and soap. Sanitizing hand wipes can be used in lieu of hand washing. Hand Sanitizer is not an acceptable cleanser for the prevention of food allergic reactions.
• Student’s lunch table is cleansed with a fresh dedicated cleaning solution and towel prior to the arrival of the allergic student.
• Parents of the child with food allergy and the School Nurse should refer to the Klein ISD Nutrition & Food Services allergen list found at: http://www.kleinisd.net/default.aspx?name=fsfood.nutrition. Utilize this list to help students plan food selections in advance of arrival to the cafeteria.
• The reward and/or instructional use of food in the student’s classroom should be avoided. If it cannot be avoided, then nutritional labels should be carefully scrutinized by the classroom teacher and school nurse for presence of allergens. The School Nurse will require 2 week advance notice to review the food selection and nutrition labels.
• The parent of the food allergic student should provide a supply of safe snacks for use during standardized testing, classroom celebrations, etc.
• With parental permission, classroom parents should receive a letter notifying them that a student with a life threatening food allergy is in the classroom.
• Parents should refrain from providing known allergens for classroom celebrations. Non-food items can be encouraged for classroom celebrations.
HEALTH SERVICES 2017
• Parents wishing to provide food for classroom celebrations are required to submit food nutritional facts 2 weeks in advance of any classroom celebration. The school nurse will review the ingredients and packaging for the presence of known food allergens.
• If the student rides a Klein ISD bus, it is recommended the student have an assigned seat just behind the bus driver, at least through 3rd grade. Variations to this recommendation may be made based on student maturity and history of self-care.
• Students with a licensed health care provider, parent, and school nurse permission will be allowed to carry an epinephrine auto injector on their person.
o The school nurse will verify the students’ competence to self-administer. It should be noted that even when individuals demonstrate skill in self-administration during practice, they may be too anxious to self-administer in an emergency. School staff should be prepared to act quickly.
o The student is required to have an AAP that is reviewed by a licensed healthcare provider annually.
• The school nurse will have two weeks’ advance notice of field trips so appropriate plans can be made for food, training, and medication administration.
• The food allergic student will avoid the food allergen(s) by not sharing food with classmates and not accepting food that has not been planned in advance.
• The school will take threats and/or harassment related to the food allergy seriously.
HEALTH SERVICES 2017
KISD SNACK GUIDELINES
Pursuant to state law, KISD permits parents/guardians or grandparents to bring a birthday snack for their child's birthday or other school-designated functions. In addition, state law requires each school district to maintain Guidelines for Children at Risk for Anaphylaxis Related to Food Allergy. The following procedures apply to both parent and staff provided snacks:
Parent/Guardian Provided Snacks The campus nurse will be given a two week advanced written notice of the parent’s/guardians decision to provide a snack. This notice allows time for the nurse to determine if allergens are present in the proposed snack and to arrange for suitable substitution if an allergen is identified.
• No substitutions may be made once the campus nurse is given this notice. • Birthday snacks will be distributed at the end of the lunch period, after students have had a
nutritious meal as defined by the School Lunch Program and Texas Department of Agriculture.
• Written consent from a parent/guardian must be obtained before a student will be permitted to have a birthday or other snack.
o Campuses may utilize an annual or individual parent letter requesting written consent.
• Parents/guardians are encouraged to obtain snacks through the Klein ISD Nutrition & Food Services Department. With advance notice, the Nutrition & Food Services Department will prepare selected snacks. Any parent/guardian who provides a snack from a vendor other than KISD must:
o Submit to the campus nurse two weeks in advance of serving the snack: A complete list of ingredients.
1. In the case of commercially prepared food, the list on the product label will be acceptable.
All snacks must be wrapped and packaged in a disposable container. Schools will not be responsible for parents’ personal kitchen items.
Children will not be permitted to carry snacks to school. Snacks for individual consumption, such as bagels, muffins, cupcakes, etc.,
must be individually wrapped.
Klein ISD Provided Snacks
The use of food for instructional and reward purposes may put students at risk for severe allergic reactions.
HEALTH SERVICES 2017
• When teachers plan to utilize food for instructional and reward purposes, the campus nurse must be given two weeks’ prior notice of the decision to provide said snack. This notice allows time for the nurse to determine if allergens are present in the proposed snack and to arrange for suitable substitution if an allergen is identified.
• No substitutions may be made once the campus nurse is given this notice. • Written consent from a parent/guardian must be obtained before a student will be permitted
to have a Klein ISD provided snack. o Campuses may utilize an annual or individual parent letter requesting written
consent.
In keeping with the KISD Wellness Policy FFA (Local) - X, parents/guardians/teachers are encouraged to provide a non-food treat or instructional material for their child’s birthday celebration, such as pencils, erasers, stickers or markers. If a food treat is preferred, healthy treats are encouraged, such as fresh fruit, yogurt, granola bars, etc.
HEALTH SERVICES 2017
EVALUATION
• Should a student experience a food related allergic or anaphylaxis event at school, a Post Event Review will be conducted by the campus Registered Nurse in collaboration with the Campus Food Allergy Management Team. This review should include: • Identify, if possible, the source of allergen exposure and take steps to prevent future
reactions. • Identifying and interviewing those who were involved in the emergency care of the student
and those that witnessed the event. • Meeting with school staff to dispel any rumors and review administrative regulations. • With parent permission, provide factual information to parents and students that complies
with FERPA law and does not identify the individual student. • If the allergic reaction is thought to be from food provided by the school food service, work
with the Nutrition & Food Services Department to ascertain what potential food item was served/consumed, how to reduce risk in the cafeteria by reviewing food labels, minimizing cross-contamination and other strategies.
• Review of the medication orders, FAAP/EAP, IHP, and/or the 504 Plan and amend to address any changes that were made by the student’s healthcare provider. Alterations may require new forms to be signed by the parents.
• If an epinephrine auto-injector was utilized during the reaction, ensure that the parent/guardian replaces it with a new one.
• In the rare event of a fatal reaction, the Klein ISD Crisis Team will be activated to assist the school community in dealing with the death. Healthcare providers with knowledge about food allergies should be on hand to answer questions.
• Return the completed Anaphylaxis Event/Epinephrine Administration Review packet to the office of the Health Services Coordinator.
HEALTH SERVICES 2017
APPENDIX
SUPPORTING DOCUMENTATION
• Klein ISD Request for Food Allergy Information o English o Spanish o Vietnamese
• Allergy Action Plan • Permission to Carry Anaphylaxis Auto-Injector
o English o Spanish
• Klein ISD Nutrition and Food Service Special Dietary Accommodations form • Sample Individualized Health Plan • Consent to Release Food Allergy Information
o English o Spanish
• Classroom parent notification letter o English o Spanish
• Klein ISD Snack Permission – Annual Option o English o Spanish
• Klein ISD Snack Permission – Individual Occurrence o English o Spanish
• Milk substitution letter o English o Spanish
• Klein ISD Post Event Review for Food Allergy Reaction
This plan will be reviewed yearly for necessary updates based on Klein ISD experience and current scientific evidence related to food allergy management.
This document is to be maintained in the Student’s Cumulative Folder
Health Services 2017
Dear Parent: This form allows you to notify Klein ISD that your child has a food allergy or severe food allergy. This notification will enable Klein ISD to initiate the plans necessary to provide for your child’s safety. “Severe food allergy” means a dangerous or life-threatening reaction of the human body to a food-borne allergen introduced by breathing, eating, or skin contact that requires immediate medical attention. NOTE – KLEIN ISD CANNOT CHANGE FOOD ITEMS UNLESS YOU PRESENT THE KLEIN ISD DIET MODIFICATION FORM SIGNED BY YOUR MEDICAL PROVIDER. Please check one of the boxes to let us know if your child has a food allergy.
□ My child DOES NOT have a food allergy.
□ My child has a food allergy as noted below. (Please see the school nurse for a food allergy forms packet.)
Foods to which your child is
allergic How does your child react when they come in
contact with this food?
Life-Threatening?
� Yes � No
� Yes � No
The District will maintain the confidentiality of the information provided above and may disclose the information to teachers, school counselors, school nurses, and other appropriate school personnel only within the limitations of the Family Educational Rights and Privacy Act and District policy. Student Name: _______________________________________ Date of Birth: _________________ School: ____________________________________________ Grade: ______________________ Parent/Guardian Name: ________________________________ Work Phone: _______________ Mobile Phone: _______________ Home Phone: __________________ Parent/Guardian Signature: ______________________________ Date: ________________ Date form received by Campus: __________________________ Nurse Signature: ______________________________________ Date _________________
This document is to be maintained in the Student’s Cumulative Folder
Health Services 2017
PETICIÓN DE INFORMACION DE ALERGIAS ALIMENTARIAS Estimado Padre: La siguiente forma permite que usted notifique a Klein ISD que su hijo tiene una alergia alimentaria, o alergia alimentaria severa. Esta notificación, permite que Klein ISD inicie el plan necesario para proveer la seguridad necesaria para su hijo/a. “Alergia alimentaria severa” significa que en el cuerpo ocurrirá una reacción peligrosa, o que pone en peligro la vida, porque un alérgeno en la comida se ha introducido por inhalación, consumo de alimentos o contacto con la piel, requiriendo atención medica inmediata. NOTA – KLEIN ISD NO PUEDE CAMBIAR ALIMENTOS SI USTED NO PRESENTA LA FORMA DE MODIFICACION MEDICA DE DIETA FIRMADA POR SU PROVEEDOR MEDICO. Por favor, marque una de las casillas para hacernos saber si su hijo tiene una alergia alimentaria.
□ Mi hijo/a NO TIENE una alergia alimentaria.
□ Mi hijo/a tiene la alergia alimentaria que se muestra abajo. (por favor, visite a la enfermera de la escuela para recibir el paquete con las formas para alergias alimentarias.)
Alimentos a los que su hijo/a es
alérgico/a ¿Cómo reacciona su hijo/a cuando entra en
contacto con éste alimento?
¿Pone en riesgo su vida?
� Sí � No
� Sí � No
El Distrito mantendrá la confidencialidad de la información provista arriba, y pudiera compartirla con maestros, consejeras, enfermeras de la escuela, y otros miembros del personal de la escuela, únicamente dentro de las limitaciones dictadas por El Acta Educacional de Derechos y Privacidad de la Familia, y Políticas del Distrito. Nombre del Estudiante: ________________________________ Fecha de Nacimiento: _________________ Escuela: ____________________________________________ Grado: ____________________________ Nombre del Padre/ Guardián: __________________________________________________________________ Teléfono del Trabajo: __________________ Celular: __________________ Casa: _________________ Firma del Padre/ Guardián: ____________________________________________ Fecha: ________________ Fecha en que la forma fue recibida por la escuela: ______________________________________________________ Firma de la Enfermera: __________________________________________________ Fecha: ________________
This document is to be maintained in the Student’s Cumulative Folder
Health Services 2017
Yêu Cầu Thông Tin về Dị Ứng Thực Phẩm .
Kính gởi phụ huynh: Mẫu đơn này dành cho quý vị dùng để thông báo cho khu học chánh Klein biết về những thực phẩm mà con em quý vị phải ăn kiêng hoặc bị dị ứng nặng. Thông tin này giúp khu học chánh Klein làm kế hoạch cần thiết để bảo vệ sự an toàn cho con em quý vị. “Dị Ứng Thực Phẩm Nghiêm Trọng” có nghĩa là nguy hiểm hoặc nguy hại đến tính mạng vì sự phản ứng của cơ thể với chất gây dị ứng từ thực phẩm qua sự tiếp xúc như hít thở, ăn uống, hoặc qua làn da mà phải cần chữa trị gấp. CHÚ Ý – KHU HỌC CHÁNH KLEIN KHÔNG THỂ THAY ĐỔI THỨC ĂN NGOẠI TRỪ QUÝ VỊ CÓ GIẤY CHỨNG NHẬN CỦA BÁC SĨ VÀ CÓ CHỮ KÝ CỦA BÁC SĨ NỘP CHO KHU HỌC CHÁNH. Xin chọn một ô dưới đây cho chúng tôi biết nếu con em quý vị có bị dị ứng thực phẩm.
□ Con tôi KHÔNG BỊ dị ứng thực phẩm.
□ Con tôi bị dị ứng thực phẩm theo liệt kê dưới đây. (Xin gặp y tá của trường để có hồ sơ dị ứng thực phẩm.)
Thực phẩm nào con quý vị bị dị ứng?
Con quý vị bị phản ứng thế nào
khi bị dị ứng thực phẩm?
Nguy hiểm tánh mạng
không? Khoanh tròn.
Có / Không
Có / Không
Khu học chánh sẽ giữ bảo mật về những thông tin đã cung cấp trên và có thể chỉ chia sẻ thông tin này với giáo viên, tư vấn của trường, y tá của trường, và những nhân viên có liên quan trong giới hạn của Quyền Giáo Dục Gia Đình “Family Education Rights” và Luật Bảo Mật và Chính Sách Học Khu “Privacy Act and District policy” Tên học sinh: _______________________________________ ____ Ngày sinh: _________________ Trường: _______________________________________________ Lớp: ______________________ Tên phụ huynh/Bảo hộ: ___________________________________ Đ/T sở làm: ________________ Đ/T di động: ________________ Đ/T nhà: ___________________ Chữ ký phụ huynh/Bảo hộ: ________________________________ Ngày: _____________ Ngày trường nhận được đơn: _______________________________ Chữ ký y tá trường: ______________________________________ Ngày ______________
TURN FORM OVER Form provided courtesy of the Food Allergy & Anaphylaxis Network (www.foodallergy.org) 9/2011
Campus: ______________ Student ID: ____________ Grade: ________ Name: D.O.B.: / /
Allergy to:
Weight: lbs. Asthma: Yes (higher risk for a severe reaction) No
Extremely reactive to the following foods: THEREFORE: If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten. If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted.
Medications/Doses Epinephrine (brand and dose): Antihistamine (brand and dose): Other (e.g., inhaler-bronchodilator if asthmatic):
Monitoring Stay with student; alert healthcare professionals and parent. Tell rescue squad epinephrine was given; request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of epinephrine can be given 5 minutes or more after the first if symptoms persist or recur. For a severe reaction, consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached. See back/attached for auto-injection technique. __________________________________ __________ __________________________________ __________ Parent/Guardian Signature Date Physician/Healthcare Provider Signature Date __________________________________ __________ School Nurse Signature Date
1. INJECT EPINEPHRINE IMMEDIATELY
2. Call 911 3. Begin monitoring (see box
below) 4. Give additional medications:* -Antihistamine -Inhaler (bronchodilator) if asthma *Antihistamines & inhalers/bronchodilators are not to be depended upon to treat a severe reaction (anaphylaxis). USE EPINEPHRINE.
1. GIVE ANTIHISTAMINE 2. Stay with student; alert
healthcare professionals and parent
3. If symptoms progress (see above), USE EPINEPHRINE
4. Begin monitoring (see box below)
MILD SYMPTOMS ONLY: MOUTH: Itchy mouth SKIN: A few hives around mouth/face, mild itch GUT: Mild nausea/discomfort
Any SEVERE SYMPTOMS after suspected or known ingestion: One or more of the following: LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, confused THROAT: Tight, hoarse, trouble breathing/swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body Or combination of symptoms from different body areas: SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) GUT: Vomiting, diarrhea, crampy pain
Place
Student’s Picture
Here
TURN FORM OVER Form provided courtesy of the Food Allergy & Anaphylaxis Network (www.foodallergy.org) 9/2011
PROCEDURE FOR EPIPEN OR EPIPEN JR AUTO-INJECTOR Step 1. Prepare EpiPen or EpiPen Jr for Injection
Note: The needle comes out of the orange tip. To avoid an accidental injection, never put your thumb, fingers or hand
over the orange tip. If an accidental injection happens, get medical help right away. Step 2. Administer EpiPen or EpiPen Jr for Injection
If you are administering to a young child, hold the leg firmly in place while administering an injection.
Step 3. Get Emergency Medical Help Now
You may need further medical attention, CALL 911. You may need to use a second EpiPen or EpiPen Jr Auto-Injector if symptoms continue or recur.
PROCEDURE FOR EPINEPHRINE USP AUTO-INJECTOR
An allergy response kit should contain at least two doses of epinephrine, other medications as noted by the student’s physician, and a copy of this Allergy Action Plan.
A kit must accompany the student if he/she is off school grounds (i.e., field trip).
Contacts Doctor: _________________________ Phone: (___) _____-_________
Parent/Guardian: _________________ Phone: (___) _____-_________ Other Emergency Contacts:
Name/Relationship: _________________________Phone: (___) _____-_______
Name/Relationship: _________________________Phone: (___) _____-_______
Health Services 2017
PERMISSION TO CARRY ANAPHYLAXIS AUTO INJECTOR
Student’s Name: ____________________________ Birth Date: ____________ Name of Medication: ________________________________ Purpose of Medication: ______________________________ Dosage: ___________________________ Times and Circumstances under which medication may be administered: ___________________________ ___________ Physician’s Signature Date I authorize my child to self administer his/her prescription anaphylaxis medication as per doctor’s Allergy Action Plan while on school property or at a school-related event or activity. I understand that my child is responsible for the proper handling and carrying of the auto injector and that it must be kept out of the reach of other students at all times. The medication must have a current prescription label indicating that it has been prescribed for my child. My child and I agree to the conditions stated below. Failure to comply will result in this medication being stored in the school clinic. 1. A copy of the doctor’s orders and parent permission must be kept on file in the nurse’s office. 2. The auto injector or box will have the prescription label on it stating the student’s name and
directions. If the label is on the box the pen must be carried in the box at all times. 3. If it is necessary for an injection to be administered it will be done in the presence of an adult,
when feasible. 4. The nurse will be sent for or the student will be escorted to the clinic immediately after the
injection for further medical treatment and observation. 5. Parent and EMS/911 will be notified. 6. Student and parent must agree to be responsible for the proper handling and carrying of the
injector pen. It must be kept out of reach of other students at all times. 7. It is advised that a second anaphylaxis auto-injector be kept in the school clinic to facilitate
rapid treatment. ___________________________ ____________________________ ___________ Parent/ Guardian Signature Printed Parent/ Guardian Name Date ____________________________ ____________________________ ___________ Student Signature Printed Student Name Date
PERMISO PARA LLEVAR EL AUTO-INYECTOR PARA ANFILAXIA
Nombre del Estudiante: ____________________________ Fecha de Nacimiento: ___________ Nombre del Medicamento: _______________________________________________________ Propósito del Medicamento: ______________________________________________________ Dosis: ______________________________________________ Horario y circunstancias bajo las cuales debe ser administrado el medicamento: ________________________________________________ __________________ Firma del Médico Fecha Yo autorizo a que mi hijo/a se auto-administre la medicina para anafilaxis recetada por el médico bajo el Plan de Acción para Alergias, mientras se encuentra en lugares de propiedad escolar, o en una actividad o evento relacionados con la escuela. Entiendo que mi hijo/a es responsable por el manejo y uso apropiado del auto-inyector, y que el mismo debe mantenerse fuera del alcance de otros estudiantes en todo momento. El medicamento debe tener una etiqueta actualizada indicando que ha sido recetado para mi hijo/a. Mi hijo/a y yo estamos de acuerdo con las condiciones que se muestran abajo. El fallar con el cumplimiento de estas condiciones resultará en que la medicina sea almacenada en la clínica de la escuela.
1. Una copia de las órdenes del médico y el permiso de los padres deben ser guardados en los archivos en la oficina de la enfermera.
2. El auto- inyector o la caja deben tener la receta en una etiqueta que también indique el nombre del
estudiante y su dirección. Si la etiqueta está en la caja, el inyector debe ser llevado en la caja en todo momento.
3. En caso de ser necesaria la administración de una inyección, esta debe realizarse en presencia a de un
adulto, mientras sea posible.
4. Inmediatamente después de la inyección, se debe llamar a la enfermera, o se debe llevar al estudiante a la clínica de la escuela para continuar la observación y el tratamiento médico.
5. Se notificará al padre y a los servicios de emergencia del 911.
6. El estudiante y los padres deben de estar de acuerdo con el manejo adecuado y transporte del auto-
inyector. Debe mantenerse fuera del alcance de otros estudiantes en todo momento.
7. Se recomienda mantener un segundo auto-inyector para anafilaxia en la clínica de la escuela para facilitar un tratamiento rápido.
______________________________ ___________ ________________________________ Firma del Padre Fecha Firma del Estudiante
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D. C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. This institution is an equal opportunity provider.
Request for Special Dietary Accommodations
Student Name__________________________________ Date of Birth _________________________________ Klein ISD ID #_________________________________ Campus Name________________________________ Parent/Guardian Name___________________________ Parent Phone Number(s) _________________________ Email_______________________________________
1. Will the student eat meals from the food service department? Breakfast ____ Lunch ____
2. Check one of the following that would require dietary accommodation:
Life Threatening Allergy: Complete Section A
Physical/Mental Impairment (Immune, Digestion, Respiration, etc.): Complete Section B
Section A
Life Threatening Food Allergies: _______________________________________________________
1. Foods to be omitted: ____ Fluid Milk ____ All dairy products ____ Wheat ____ Gluten
____ Whole Eggs ____ All foods containing egg as an ingredient ____ Soy ____ Seafood
____ Whole Corn ____ All foods containing corn additives (corn syrup, etc.)
____ Peanuts ____ All Nuts ____ All foods produced in a facility with nut containing products.
Other (Please be Specific):_______________________________________________________________
2. Foods to Substitute (please check one box) Foods not containing allergen
Specific food items: ________________________________________________________________
Section B
Physical/Mental Impairment: ____________________________________________________________________________
Dietary Accommodation Required ________________________________________________________________________
______________________________________________________________________________________________________
___________________________________ ___________________________________ ___________________ Health Care Provider’s Signature Clinic/ Facility Name & Address Telephone ___________________________________ __________________ Health Care Provider’s Printed Name Date form completed
For Office Use Only Date Received from Physician: ________________ Received by: _______________________ Date Emailed to Nutrition & Food Services ([email protected])______________________ Forwarded by: ______________________
Date: <<CurrentDate>>
Name: _______________________________ Medical Diagnosis:____________________________ Birth Date: ____________________________ ID:____________________________
____________________has the potential for anaphylactic shock secondary to severe food allergy. (Name)
Nursing Diagnosis
Goals Interventions Outcome
Risk for ineffective breathing related to bronchospasm and inflammation of airways secondary to allergic reaction.
Student will have IHP in place to include student, parental and staff roles in preventing and managing an anaphylactic reaction
Secure medical documentation of food allergy, treatment plan, food substitutions (Emergency Action Plan=EAP)
Educate school staff on early signs of potential anaphylaxis and appropriate steps in emergency care.
o School wide staff awareness training on recognition of signs of allergic reaction.
o Student specific training for classroom, administrative, cafeteria, custodial and transportation personnel.
o Train designated staff in use of Epinephrine auto-injector, first aid care, EMS contact.
201_-201_ Staff Trained (add to list yearly)
___________________
___________________
___________________
Designated personnel receive copy of EAP & IHP.
*Medical documentation received-EAP. *Yearly staff awareness training documented. *Student specific training delivered and documented in student file. *Staff demonstrates proper use of epinephrine auto-injector. In event of allergic reaction, staff responds in accordance with EAP. *Staff responds to student report of allergen exposure and either supports student providing self-care or by administering epinephrine auto-injector. *Post crisis review conducted in event of food allergen exposure.
Student will demonstrate awareness of the significance of allergic reactions, symptoms and treatment.
Review with student:
Food allergen and potential that allergen may be a
“hidden” ingredient.
Procedures to follow if they perceive a situation
that may expose them to food allergen.
Treatment methods including how/when to report
allergic symptoms to school personnel.
*Student will read food labels
before ingestion.
*Student will not accept food
offered by other students
*Student demonstrates
assertiveness when encountering
situations that have potential to
result in exposure to food
allergen.
Ensure that students who have permission to carry epinephrine auto-injector have adequate knowledge to perform self-care. Educate as necessary to ensure student and school community safety.
*Student will identify allergic
reactions, notify school personnel
and treat immediately.
Establish a food
safe environment
for students with
food allergies.
Educate staff regarding allergen and institute
environmental controls.
All students/personnel wash hands or use hand wipes before and after food consumption/handling. Emphasize that hand sanitizer is NOT effective in removing allergens from hands or other surfaces.
Review food allergy and exposure prevention with food service staff.
Secure medical documentation for food substitution.
Secure “emergency meal” from parent in event food allergen cannot be avoided.
Review cleaning procedures with custodial staff. Establish a food safe environment for students with food allergies.
Notify classroom parents of need to restrict presence of food allergen in student’s classroom activities.
Avoid use of food for instructional/reward purposes.
Adhere to policy of NO food on Klein ISD buses except for students with medical need.
Separate seating for food allergic child and students requiring food on bus.
Minimum 2 week advance planning for field trips and other off campus activities.
Facilitate student participation in full range of school activities.
*Student is NOT exposed to
allergen and has NO episodes of
allergic reaction.
Potential for
diminished self-
esteem secondary
to food allergy
diagnosis.
Protect/Enhance
student’s self-
image.
Zero tolerance for bullying related to food allergy.
Educate student on assertiveness techniques.
Empower student to educate classmates.
*Student does not experience
bullying or discrimination related
to food allergy.
*Student demonstrates positive
self-esteem related to food
allergy via verbal and non-verbal
communication.
Physician Name (Printed or Stamp) ________________________________ Physician Signature: ____________________________________________ Date: __________________ Parent Name Printed: ___________________________________________ Parent Signature: _______________________________________________ Date: __________________ Registered Nurse Name (Printed): _________________________________ Registered Nurse Signature: ______________________________________ Date: _________________
Health Services 2017
CONSENT TO RELEASE FOOD ALLERGY INFORMATION
Dear Parent/ Guardian,
The Campus Allergy Management Team works to minimize exposure to food allergens for all students.
While Klein ISD Nutrition & Food Services is dedicated to preventing allergen exposure, Klein ISD
cannot control food items brought from home by other students. By alerting the parents of other students
on the importance of allergen avoidance at school, we can minimize the occurrence of food allergen
exposure to your child.
Klein ISD has formulated a parent letter that can be distributed to your child’s class advising them of a
student with a food allergy. The letter does not identify your child, but details what food allergens should
be left at home and steps to avoid cross contamination. A copy of this letter is attached.
By signing this consent, you are stating you have reviewed the aforementioned parent letter and agree to
have the letter distributed to your child’s homeroom class.
________________________________________________________ _______________ Student’s Name Student ID
________________________________________________________ _______________ Signature of Parent, Guardian, Surrogate Parent, or Adult Student Date: ________________________________________________________ Printed Name _______________________________________________________ ______________ Signature of Interpreter, if used Date: _______________________________________________________ Printed Name of Interpreter, if used
Health Services 2017
CONSENTIMIENTO PARA DIVULGAR INFORMACIÓN SOBRE ALERGIAS ALIMENTARIAS
Estimado Padre/Tutor,
El Equipo para el Manejo de las Alergias en la escuela trabaja para minimizar la exposición a los alérgenos alimentarios para todos los alumnos. Aunque que los Servicios de Nutrición y Alimentación de Klein ISD están dedicados a prevenir la exposición de los alérgenos, Klein ISD no puede controlar los alimentos que otros estudiantes traen de la casa. Al mantener a los padres de otros estudiantes informados de la importancia de evitar los alérgenos en la escuela, podemos minimizar el exponer a su hijo/hijo a los alérgenos de alimentarios.
Klein ISD ha formulado una carta para padres que se puede distribuir a los estudiantes del salón de clase
de su hijo/hija informándoles que un estudiante tiene alergias alimentarias. La carta no identifica a su
hijo/hija, pero si les informa que tipo de alimentos deben dejarse en casa y los pasos para evitar
contaminación. Se ha incluido una copia de esta carta.
Al firmar éste consentimiento, usted está declarando que ha revisado la carta para los padres, antes
mencionada, y que está de acuerdo en que la carta sea distribuida a la clase de su hijo/hija.
______________________________________________________ _______________ Nombre del Estudiante Identificación del Estudiante
______________________________________________________ _______________ Firma del Padre, Tutor, Padre Sustituto, Estudiante Adulto Fecha: ______________________________________________________ Nombre Impreso ______________________________________________________ ______________ Firma del Intérprete, si se usó Fecha: ______________________________________________________ Nombre Impreso del Intérprete, si se usó
Health Services 2017
Dear Parents,
A student in your child’s class has a severe allergy to __________________________. A child with this type
of allergy is at risk of developing anaphylaxis; a potentially life threatening event. Anaphylaxis can
occur when a person eats; touches or inhales the food they are allergic to. Therefore, in order to
promote the safety and well being of this student, we would like your cooperation with the
following procedures.
• You may send foods containing __________________ for lunch only.
• Please do not enclose candy or other treats with seasonal cards.
• If your child ate ____________________________ for breakfast, make sure that his/her hands are
washed with soap and water before leaving for school. Water alone or hand sanitizers do
not remove allergens.
Thank you for your cooperation with our food allergy management procedures.
_________________________________________________
School Nurse Signature
Tel: ____________________________________________
Health Services 2017
Estimados Padres,
Un estudiante del salón de clase de su hijo/hija tiene una alergia severa a/al __________________________.
Un niño con este tipo de alergia corre el riesgo de desarrollar anafilaxia; un evento potencialmente
mortal. Anafilaxia puede ocurrir cuando una persona come, toca o inhala el alimento al cual es
alérgico. Por lo tanto, con el fin de promover la seguridad y el bienestar de éste estudiante, nos
gustaría contar con su cooperación con los siguientes procedimientos.
Por favor, no envié alimentos que contienen __________________ para ser consumidos como bocadillos
en el salón de clase. Usted puede enviar estos productos para consumir durante el almuerzo en la
cafetería.
• Por favor no envié caramelos u otras golosinas con las tarjetas de los días festivos.
• Si su hijo/hija comió ____________________________ para el desayuno, asegúrese de que se lave
las manos con agua y jabón antes de salir a la escuela. El utilizar agua sin jabón o sin
desinfectante antibacterial para las manos no elimina los alérgenos.
Gracias por su cooperación con nuestros procedimientos para las alergias alimenticias.
Si usted tiene alguna pregunta, por favor comuníquese con la enfermera de la escuela.
_______________________________________ Firma de la enfermera certificada (School nurse Signature) ______________________________________________________________ Número de teléfono
Health Services 2017
KISD SNACK GUIDELINES
While the use of non food rewards and celebrations is always preferred, Klein ISD acknowledges that there are instances when foods are used appropriately as part of instruction. Additionally the Texas Education Code §28.002(L-3)(1) permits parents/guardians or grandparents to provide a birthday snack for their child's birthday. The following guidelines apply to such snacks:
• The campus nurse will be given a two week advanced written notice of the parent / guardian or faculty decision to provide any food items to students.
• No substitutions may be made once the campus nurse is given this notice. • Birthday snacks will be distributed by Klein ISD staff at the end of the lunch period, after
students have had a nutritious meal as defined by the School Lunch Program and Texas Department of Agriculture.
• Written consent from a parent/guardian must be obtained before a student will be permitted to receive and eat a birthday / classroom snack.
• Campuses may utilize an annual or individual parent letter requesting written consent. • Parents/guardians are encouraged to obtain snacks through the Klein ISD Nutrition & Food
Services Department. With advance notice, the Nutrition & Food Services Department can provide a choice from an assortment of snacks.
• Any parent/guardian who provides a birthday/ seasonal snack not provided by Klein ISD Nutrition & Food Services must:
o Submit to the campus nurse two weeks in advance of serving the snack: A complete list of ingredients included in the snack. In the case of commercially prepared food, the product label must be provided,
including the complete ingredient list and all information about production line exposure to known food allergens.
o All snacks must be individually wrapped and packaged in a disposable container. Schools will not be responsible for parents’ personal kitchen items.
o All snacks must be delivered by the parent to the campus main office, where a written receipt for the item will be prepared. Children will not be permitted to carry snacks to school.
In keeping with the Klein ISD Wellness Policy, parents are encouraged to provide a non food treat for their child’s birthday celebration, such as pencils, pens or stickers. If a food treat is preferred, parents are encouraged to provide a healthy treat for students, such as fruit, yogurt, granola bars, etc.
Health Services 2017
KLEIN ISD SNACK PERMISSION
Dear Parent/ Guardian,
Throughout the school year your child’s class may be served a snack as part of instruction, at a
classroom party or as part of a birthday celebration. The snacks may be provided by the Campus
Principal, classroom Teacher, Parent Teacher Organization or by a Parent/Guardian or grandparent of a
fellow classmate. Written consent from a parent/guardian must be obtained before a student will be
permitted to have a birthday snack. This letter allows you to state if you want to be contacted each
time a snack is being served or for you to provide a yearly agreement.
Please review the information, indicate your preference and return this letter to
_______________________ by _____________________.
(Classroom / Homeroom) (Date)
PLEASE INDICATE YOUR PREFERENCE REGARDING SNACKS:
Student Name: ______________________ Date of Birth: _________________________
☐ YES – you may provide school snacks to my child throughout the school year and I do not need to be contacted each time. (Please note by checking this box, you are aware the snack will be provided to the student regardless of its ingredients).
☐NO - you MAY NOT provide school snacks to my child without my consent and I NEED to be contacted each time.
I acknowledge it is the responsibility of the Parent/Guardian to notify the school nurse should my child’s food allergy status change. ____________________________________ ________________________________ Parent/Guardian Signature Today’s Date
___________________________________ _______________________________ PRINT Parent/Guardian name Contact telephone number
Health Services 2017
KLEIN ISD INDIVIDUAL SNACK PERMISSION
Dear Parent, Your child’s class will be served a snack at the date and time listed below. Please review the information, indicate your preference and return this letter to the homeroom teacher by _____________________. The snack will be provided by: ☐ Campus Principal ☐ Parent/guardian or grandparent of a fellow classmate
☐ Parent Teacher Organization (PTO) ☐ Other: _____________________________________
☐ Classroom Teacher
Date snack will be served: ______________ Snack will be served: ☐ After lunch (birthday snack) ☐ Class Party ☐ For instruction ☐ Other: ______ Commercially prepared or KISD Nutrition and Food Services snacks are preferred.
Description of food item, including complete ingredient list:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PLEASE INDICATE YOUR PREFERENCE REGARDING THIS SNACK:
☐ My child may consume the snack listed.
☐ My child may not consume the snack listed and I will provide a substitute food item.
________________________________ ________________________________ Parent/Guardian Signature Today’s Date
____________________________________ ________________________________ PRINT Parent/Guardian name PRINT Student Name
Health Services 2017/ MO
KLEIN ISD PERMISO PARA PROVEER REFRIGERIO
Estimado Padre, A su hijo se le servirá un refrigerio en la fecha que se muestra abajo. Por favor, revise la información indicando su preferencia y regrese ésta carta al maestro/a de su hijo el día _____________________. El refrigerio será provisto por: ☐ Director de la Escuela ☐ Padre/ guardián de un compañero de clase
☐ Organización de Padres (PTO) ☐ Otro: _____________________________________
☐ Maestro/a
Fecha en que se servirá el refrigerio: ______________ Hora en que se servirá el refrigerio: _______________ ☐ Después de almuerzo (Refrigerio de cumpleaños) ☐ Celebración en la clase ☐ Como parte de la instrucción ☐ Otro: ___________ Se prefieren refrigerios preparados comercialmente o por el Servicio de Comida y Nutrición de Klein ISD.
Descripción del alimento, incluyendo la lista completa de los ingredientes:
________________________________________
________________________________________
________________________________________
POR FAVOR, INDIQUE SU PREFERENCIA PARA ESTE REFRIGERIO:
☐ Mi hijo/ a puede consumir el refrigerio mencionado.
☐ Mi hijo/a no puede consumir el refrigerio mencionado, y yo proveeré un alimento en sustitución.
____________________________________ ________________________________ Firma del padre/ guardián Fecha de hoy
____________________________________ ________________________________ Nombre IMPRESO del padre/ guardián Nombre IMPRESO del estudiante
Health Services
Milk Substitution Letter
Student Name: _________________________________ D.O.B:_________________
School: _________________________________________
The above named student cannot drink cow’s milk. Please select a drink option from the choices listed below:
I want my child to have soy milk.
I will provide my child’s drink or I will send money for juice and water bottle purchases.
Parent/ Guardian Signature: ___________________________________ Date: ________________
Parent/ Guardian Printed Name: ________________________________
For Office Use Only Date Forwarded to Nutrition & Food Services: ____________________ Forwarded by: _____________________ Date Received at Nutrition& Food Services: ______________________ Received by: ______________________
Servicios de Salud
Carta de Substitución de la Leche
Nombre del Estudiante: ________________________ Fecha de Nacimiento: ____________
Escuela: ____________________________________
El estudiante mencionado no puede beber leche de vaca. Por favor seleccione una opción de bebida de las opciones a continuación:
Quiero que mi hijo/hija beba leche de soya.
Proporcionaré la bebida de mi hijo/hija o enviaré dinero para que compre jugo y botella de agua.
Firma del Padre/Tutor: ______________________________ Fecha: ______________
Nombre Impreso del Padre/Tutor: ___________________________________________
For Office Use Only Date Forwarded to Nutrition & Food Services: ____________________ Forwarded by: _____________________ Date Received at Nutrition& Food Services: ______________________ Received by: ______________________
Anaphylaxis Event/Epinephrine Administration
EMS Referral Form
Date of occurrence: __________ Time of occurrence: ________AM / PM School: ________________________
Client Name: _________________________________ DOB (If known): ____________ Age (If known): _______
Type of Client: ☐ Student ☐ Staff ☐ Visitor Gender: ☐ M ☐ F
Yes No Unknown History of allergy? History of Anaphylaxis? Allergy Action Plan Available? Previous Epinephrine Use? Diagnosis/history of asthma?
Initial Vital Signs: Pulse_______ (bpm) Respiratory Rate: ________ BP_____ /_____ Temp: _______⁰F
If known, specific trigger that precipitated this allergic episode:
Food _______________________ Insect Sting ______________ Exercise ______________________
Medication __________________ Latex ___________________ Other / Unknown _______________
If food: ☐ Ingested ☐ Touched ☐ Inhaled ☐ Other
Location of onset of symptoms: ☐ Classroom ☐ Cafeteria ☐ School Clinic ☐ Playground ☐ Bus ☐Other: ___________
Epinephrine Auto-injector administered by: ☐ RN ☐ Client ☐ Trained School Staff ☐ Other ___________________
Time of Epinephrine administration: ______________ AM/PM Location of injection: ☐ Right Thigh ☐ Left Thigh Dose: ☐ 0.3mg ☐ 0.15mg Approximate time between onset of symptoms and administration of Epinephrine: _______
Antihistamine Administered? ☐ Yes ☐ No Med/Dose: ________________________ Time: ________AM / PM
Time EMS notified (911): __________ AM / PM
If required - Time of second dose of Epinephrine::_______ AM/PM Location of injection: ☐ Right Thigh ☐ Left Thigh Dose: ☐ 0.3mg ☐ 0.15mg
Campus contact information:
Front Office: ____________________________
Clinic: __________________________________
Retain copy of EMS Referral Form for Student Health record
Complete all 3 pages.
Revised and used with permission from the National Association of School Nurses
KLEIN INDEPENDENT SCHOOL DISTRICT
Anaphylaxis Event/Epinephrine Administration Review
Demographics and Health History
Date/Time of occurrence: ________________/______________AM PM School: _________________________________________
Client Name: ________________________________________ DOB: _____________________ Student Id:_________________________
Type of Client: Student Staff Visitor Gender: M F
History of allergy? Yes No Unknown History of Anaphylaxis? Yes No Unknown
Allergy Action Plan Available? Yes No Previous Epinephrine Use? Yes No Unknown
Diagnosis/history of asthma? Yes No Unknown
Trigger that precipitated this allergic episode: ______________________________________________________________________________
School Plans and Medical Orders
Individual Health Care Plan in place? Yes No
Written school district plan for management of life-threatening food allergy in place? Yes No
Did individual have a specific order for epinephrine? Yes No Unknown Expiration date of epinephrine __________________
Epinephrine Administration Incident Reporting
Initial Vital Signs: Pulse_________bpm Respiratory Rate: ____________ BP_________ /__________ Temp: ____________________
If known, specific trigger that precipitated this allergic episode:
Food ________________________ Insect Sting _______________________ Exercise Medication _____________________
Latex Other ______________________________________________________ Unknown
If food: Ingested Touched Inhaled Other _____________________________________________________________
Did reaction begin prior to arrival at school? Yes No Unknown
Location of onset of symptoms: Classroom Cafeteria School Clinic Playground Bus Other _____________________
Describe how exposure occurred. _______________________________________________________________________________________
___________________________________________________________________________________________________________________
Time elapse between symptom onset and communication of symptoms: ________________________________________________________
Symptoms (Check all that apply);
Respiratory GI Skin Cardiovascular Other
Cough Abdominal Discomfort Angioedema Chest discomfort Diaphoresis
Difficulty breathing Diarrhea Flushing Cyanosis Irritability Hoarse voice Difficult Swallowing General pruritis Dizziness Loss of consciousness
Nasal congestion/rhinorrhea Oral Pruritis General Rash Faint/Weak Pulse Metallic taste
Swollen (throat, tongue) Nausea Hives Headache Red eyes Shortness of breath Vomiting Lip swelling Hypotension Sneezing
Stridor Localized rash Tachycardia Uterine cramping
Tightness (chest, throat) Pallor _________________________ Wheezing
Other observable signs and symptoms:____________________________________________________________________________________
___________________________________________________________________________________________________________________
Complete all 3 pages.
Revised and used with permission from the National Association of School Nurses
First Dose Epinephrine Auto-injector administered by: RN Client Trained School Staff Other ___________________
Location of injection: Right Thigh Left Thigh Dose: 0.3mg 0.15mg Time: ______________________
Location of student when Epinephrine Auto-injector administered: Classroom Cafeteria School Clinic Other _______________
Location of Epinephrine Storage: Classroom Client Possession School Clinic Other _____________________________________
Antihistamine Administered? Yes No Med/Dose: _______________________________________ Time: ________AM PM
Approximate time between onset of symptoms and administration of Epinephrine: ________________________________________________
If administered by a student, was the student formally trained? Yes Date of training ______________ No
If administered by a faculty member, was the faculty member formally trained? Yes Date of training: __________ No training provided
Time EMS notified (911): ___________________________________ AM PM
Time parent notified of epinephrine administration: _______________ AM PM
Second Dose Second dose not required
Epinephrine Auto-injector administered by: RN Client Trained School Staff Other ___________________
Location of injection: Right Thigh Left Thigh Dose: 0.3mg 0.15mg Time: ________________________
Biphasic reaction: Yes No Unknown
If second dose of epinephrine was required, was it administered: Before EMS Arrival After EMS Arrival
Antihistamine Administered? Yes No Med/Dose: __________________________________ Time: _____________AM PM
CPR performed: Yes No
Disposition
Transferred to ER: Yes No Unknown Discharged after____________hours.
If transported by EMS, accompanied by: Parent School Nurse School Administrator Other _____________________________
Hospitalized: Yes No Discharged after____________days.
Student/Staff/Visitor Outcome: ______________________________________________________________________________________
________________________________________________________________________________________________________________
If first occurrence of allergic reaction:
1. Was the individual prescribed epinephrine in the ER? Yes ___ No ___ Unknown ____
2. If yes, who provided epinephrine auto injector training? ER ___ PCP ___ School Nurse ____
Other ________________ Unknown ____
3. Did the ER refer the individual to PCP and/or allergist for follow-up? Yes ___ No ___ Unknown ___
Comment: _________________________________________________________________________________
Complete all 3 pages.
Revised and used with permission from the National Association of School Nurses
School Follow-up
Did a debriefing meeting occur? Yes No Did family notify prescribing practitioner? Yes No Unknown
Recommendations for changes/improvements to current policy or procedures: Protocol change Policy Change
Educational change Information sharing None
Comments from debriefing:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
PRINTED NAME/SIGNATURE of attendees at post event debriefing:
Parent _______________________________________________________________________________________
School Nurse __________________________________________________________________________________
School Administrator____________________________________________________________________________
Classroom Teacher _____________________________________________________________________________
Bus Driver ____________________________________________________________________________________
Lunch Room Monitor ___________________________________________________________________________
Custodian _____________________________________________________________________________________
Other ________________________________________________________________________________________
Form completed by: ________________________________________________________ Date: ________________
Signature
________________________________________________________
Printed Name
Title: ________________________________________________________________
Phone Number (_______) ________-___________ Ext. _________ Email _________________________________________
