FILE: JHCF-AF1



STUDENT ALLERGY PREVENTION AND RESPONSE

(District Keeps Epinephrine Premeasured Auto-Injection Devices on Hand)

Staff Training Procedures

Staff training procedures regarding food allergies and anaphylactic reactions will be held annually at the beginning of each school year and as needed for new employees. As per Windsor’s Student Allergy Prevention and Response policy, the staff will be trained on:

• signs and symptoms of an allergic reaction

• the use of an Epi-Pen auto-injector

• allergy prevention awareness

• emergency response

Anaphylaxis refers to a severe allergic reaction. An allergic reaction is an immune system response to a substance that itself is not harmful but that the body interprets as being harmful. Allergic reactions range from mild to severe, even life-threatening. Foods that most commonly cause an allergic reaction are peanuts, tree nuts, shellfish, milk, wheat, soy, fish and eggs. These severe allergic reactions can occur within minutes of ingestion or a reaction can be delayed for up to two hours. At present there is no cure for food allergies and strict avoidance is the key to preventing reactions. Exposure may occur by eating the food or food contact.

|SIGNS OF AN ALLERGIC REACTION |

|MOUTH |Itching and swelling of the lips, tongue or mouth |

|THROAT |Itching and/or sense of tightness in the throat, hoarseness, hacking cough, and swelling of tongue and throat.|

|SKIN |Hives, itchy rash, and/or swelling about the face or extremities |

|STOMACH |Nausea, abdominal cramps, vomiting, and/or diarrhea |

|LUNG |Shortness of breath, repetitive coughing, and/or wheezing |

|HEART |“Thready” pulse, one feels like passing out |

|The severity of symptoms can quickly change. All above symptoms can potentially progress to a life-threatening situation! If you notice ANY |

|symptoms or if they are exposed, send or contact the nurse immediately. |

|* The bolded symptoms are the most common. |

| |

|DIRECTIONS FOR ADMINISTERING EPIPEN AND EPIPEN JR. |

|Pull off activation cap. |

| |

|Hold back tip near outer thigh (always apply to thigh). |

| |

| |

| |

| |

|Swing and jab firmly into outer thigh until auto-injector mechanism functions. Hold in place and count to 10. The Epi-Pen unit would then be |

|removed and taken with you to the Emergency Room. Massage the injection area for 10 seconds. |

PREVENTION

1. Training is provided to staff on the signs and symptoms of a severe allergic reaction as provided in the student’s Section 504 plan or IHP/AAP. Staff should be aware of and implement the emergency plan, if a reaction is suspected.

2. In collaboration with the teacher, nurse and parents/guardians of the allergic student, a classroom plan regarding the management of food in the classroom will be developed.

3. The classroom teacher will notify parents by written communication of any school-related activity that requires the use of food in advance of the project or activity (i.e. classroom parties, classroom rewards).

4. Encourage proper hand washing before and after eating.

5. All staff should be responsible for personal food consumption within the school setting with consideration to students with life-threatening food allergies.

EMERGENCY RESPONSE

1. If you are aware of a student’s exposure to a possible food allergen or notice ANY signs of an allergic reaction, contact the nurse immediately.

2. In the event a student has an allergic reaction at school and the nurse is unavailable, call 911 and administer emergency medication (i.e. Epi-Pen) as indicated by the student’s Section 504 plan or IHP.

3. When in doubt, it is better to give the emergency medication than to take the chance of the situation becoming life threatening.

4. The school principal and parent/guardian should be notified as soon as feasible.

WINDSOR C-1 SCHOOL DISTRICT

INDIVIDUAL HEALTHCARE PLAN

SCHOOL NURSE CARE PLAN

| |DOB: |DATE: |

|STUDENT: | | |

|GRAEDE/TEACHER: |HOME PHONE: |REVIEW DATES: |

|PARENTS: |EMERGENCY #: |SIGNATURES/INITIALS: |

|PHYSICIAN: | |

|DATES OF PARENT CONTACT: | |

|HOSPITAL PREFERENCE: | |

|MEDICAL DIAGNOSIS/CONDITION: SEVERE ALLERGIC REACTION | |

|MEDICATIONS/EQUIPMENT: Severe Allergy Plan attached Carries EPI-PEN | |

| | |

|Possible triggers: (check all that apply) |Usual signs and symptoms: (Check all that apply) |

|Tree nuts |Wheezing Shock |

|Peanuts |Difficulty breathing/talking Loss of consciousness |

|Eggs |Chest pain or tightness Other __________________________ |

|Medication |Itching |

|Insect bites or stings Type: ______ |Hives |

|Other: _______________________ |Swelling of face, throat, tongue or eyes |

|NURSING DIAGNOSIS |GOALS |INTERVENTIONS |EVALUATION DATES |

| | | | |

|Potential life-threatening condition | |1. Minimize exposure to triggers. |Yearly, after |

|due to allergic reaction. |Decrease number and severity | |hospitalization, and as |

| |of allergic reactions. |Inform staff members of potential |needed. |

| | |triggers and strive to eliminate them. | |

| |Quickly recognize signs of | | |

| |severe allergic reaction. |2. Assess reaction to exposure. | |

| | |Notify parent. | |

| |Stabilize after exposure. | | |

| | | | |

| | |Monitor A – airway B – breathing | |

| | |C – circulation. |Date |

| | | |Initials |

| | |CALL 911 IF SEVERE REACTION AND/OR EPI-PEN IS USED. | |

| | | | |

| | |3. Assess O2 sat. | |

| | | | |

| | |4. Administer prescribed medication after | |

| | |exposure: | |

| | |Name: Dose: | |

| | | | |

| | | | |

| | | | |

| | |May repeat in 5 minutes. | |

| | | | |

| | |Use Epi-pen per standing order, if needed. | |

| | | | |

| | |Take student’s Epi-pen on filed trip. | |

| | | | |

| | |Train at least 1 staff member going on field trip using trainer| |

| | |pen. | |

| | | | |

| | |5. Other: | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Medical Statement for Student Requiring Special Meals

|Name of Student: |School District: |

|Birth Date: |School Attended: |

|Parent Name: |Telephone: |

|Telephone: | |

|For Physician’s Use |

|Identify and describe disability, or medical condition, including allergies that require the student to have a special diet. Describe the major |

|life activities affected by the student’s disability (see back of form). |

|_____________________________________________________________________________ |

| |

|_____________________________________________________________________________ |

| |

|_____________________________________________________________________________ |

| |

|Diet Prescription (check all that apply): |

|Diabetic (include calorie level or attach meal plan) Modified Texture and/or Liquids |

| |

|Reduced Calorie Food Allergy (describe): ________________________________________ |

| |

|Increased Calorie Other (describe): ______________________________________________ |

| |

|Food Omitted and Substitutions: |

|Use space to list specific food(s) to be omitted and food(s) that may be substituted. You may attach an additional sheet if necessary. |

| |

|OMITTED FOODS SUBSTITUTIONS |

| |

|_____________________________________ _____________________________________ |

| |

|_____________________________________ _____________________________________ |

| |

|_____________________________________ _____________________________________ |

| |

|Indicate Texture: |

|Regular Chopped Ground Pureed |

| |

|Indicate thickness of liquids: |

|Regular Nectar Honey Pudding |

| |

|Special Feeding Equipment: __________________________________________________________ |

| |

|Additional Comments: ___________________________________________________________________ |

|I certify that above named student needs special school meals as described above, due to the student’s disability or chronic medical condition. |

| |

|__________________________________ ____________________________ ______________________ |

|Physician’s Signature Telephone Number Date |

| |

|__________________________________ ____________________________ ______________________ |

|Signature of Preparer or Other Contact Telephone Number Date |

| |

|I hereby give my permission for the school staff to follow the above stated nutrition plan. |

| |

|______________________________________________________ _______________________________ |

|Parent/Guardian Date |

United States Department of Agriculture

Food and Nutrition Service Instruction 783-2

7 CFR PART15b

“Handicapped person” means any person who has a physical or mental impairment which substantially limits one or more major life activities, has record of such an impairment, or is regarded as having such an impairment.

“Physical or mental impairment” means (1) any physiological disorder or condition, cosmetic disfiguration, or anatomical loss affecting one or more of the following body systems:

Neurological, musculoskeletal, special sense organs, respiratory, including speech organs, cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic skin, and endocrine or (2) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. The term “physical or mental impairment” includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairments; cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental retardation, emotional illness, drug addiction, and alcoholism.

“Major life activities” means functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

FILE: JHCF-AF1

Critical

STUDENT ALLERGY PREVENTION AND RESPONSE

(Allergy Action Plan – Physician Statement)

Allergy to: ______________________________________________________________________________

Student: ___________________________ DOB: ____________ GR: __________ Teacher: _____________

Does student have history of asthma? Yes No

Signs of an allergic reaction specific to your child: _______________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

For Minor Reaction (Check all that apply.)

1. If symptoms are: ______________________________________________________________, give

(medication, dose, route) ___________________________________________________________.

2. Call emergency contacts below.

3. Call physician below for further directions.

For Major Reaction (Check all that apply.)

1. If symptoms are: ______________________________________________________________, give

(medication, dose, route) _______________________________________________IMMEDIATELY.

2. Call EMS.

3. Call emergency contacts below.

4. Call physician below for further directions.

DO NOT HESITATE TO CALL EMS

Additional information that you want the school to consider pertaining to your child’s allergies:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Physician’s Signature: ________________________ Parent Signature: _____________________________

Date: _______________ Phone: _______________ Date: _______________ Phone: _________________

| |

|EMERGENCY CONTACTS |

| | |

|1. _____________________________________________ |2. _____________________________________________ |

|Relation: _______________________________________ |Relation: _______________________________________ |

|Phone: ________________________________________ |Phone: ________________________________________ |

|Phone: ________________________________________ |Phone: ________________________________________ |

FILE: JHCF-AF1

Critical

| |

|TRAINED STAFF MEMBERS TO ADMINISTER PERMEASURED EPINEPHRINE |

|(If any, in addition to any building school nurse) |

| | |

|1. ___________________________________________ |2. ___________________________________________ |

|Room: _______________________________________ |Room: _______________________________________ |

( ( ( ( ( ( (

Note: The reader is encouraged to review policies and/or procedures for related information in

this administrative area.

Implemented: 02/23/2011

Revised: 04/15/2011

Windsor C-1 School District, Imperial, Missouri

FILE: JHCF-AF4

Critical

STUDENT ALLERGY PREVENTION AND RESPONSE

(Epinephrine Medication Self-Administration)

Student Name: ________________________________________ Grade: _______ School Year: ________________

The Missouri Safe Schools Act of 1996 provides for students to carry self-administer lifesaving medications when the following criteria are met:

1. A licensed physician prescribed or ordered the medication for use by the child and instructed such child in the correct responsible use of the medication.

2. The child has demonstrated to the child’s licensed physician or the licensed physician’s designee, and the school nurse, if available, the skill level necessary to use the medication and any device necessary to administer such medication prescribed or ordered.

3. The child’s physician has approved and signed a written treatment plan for managing asthma or anaphylaxis episodes of the child and for medication for use by the child. Such plan shall include a statement that the child is capable of self-administering the medication under the treatment plan.

4. The child’s parent or guardian has completed and submitted to the school any written documentation required by the school, including the treatment plan required in (3) above and the liability statement required in (5) below.

5. The child’s parent or guardian has signed a statement acknowledging that the school district and its employees or agents shall incur no liability as a result of any injury arising from the self-administration of medication by the child or the administration of such medication by school staff. Such statement shall not be construed to release the school district and its employees or agents from liability for negligence. (Missouri Revised Statute: Chapter 176; Pupils and Special Services; Section 167.627;08-28-2006).

Medication Name: __________________________ Dose: __________________ Time or Interval: _________________________________

Route/Inhalation Device: ______________________ Instructions: ______________________________________________________________

Medication Name: __________________________ Dose: __________________ Time or Interval: _________________________________

Route/Inhalation Device: ______________________ Instructions: ______________________________________________________________

Allergies (List known allergies to medications, foods or air-borne substances.)

_____________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

| |

|I, the parent or legal guardian of the student listed above, give permission for this child to carry and self-administer the |

|above-listed medications. I have instructed my child to notify the school staff anytime this device is used. I understand that, absent |

|any negligence, the school shall incur no liability as a result of any injury arising from the self-administration of medication by my |

|child. |

| |

|Signature of Parent or Legal Guardian: ___________________________________________ Date: __________________________ |

| |

|Parent/Guardian: |

| |

|Name: _________________________________________ Home Phone: _________________________________________________ |

| |

|Address: _______________________________________ Work and Cell Phones: _________________________________________ |

| |

|Name: _________________________________________ Home Phone: _________________________________________________ |

| |

|Address: _______________________________________ Work and Cell Phones: _________________________________________ |

| |

|Emergency Contact: |

| |

|Name: _________________________________________ Phone #’s: ___________________________________________________ |

| |

|I, a licensed physician or nurse practitioner, certify that this child has a medical history of severe allergic reactions, has been |

|trained in the use of the listed medication, and is judged to be capable of carrying and self-administering the listed medication(s). |

|The child should notify school staff anytime the medication/injector is used. The child understands the hazards of sharing medications |

|with others and has agreed to refrain from this practice. |

| |

|Signature of Healthcare Provider: ____________________________________________________________ Date: _____________________ |

| |

|Name of Healthcare Provider: _________________________________ Phone: _______________________ Fax: ________________________ |

| |

|Address: __________________________________________________ City: _________________________ Zip: ________________________ |

( ( ( ( ( ( (

FILE: JHCF-AF4

Critical

Note: The reader is encouraged to review policies and/or procedures for related information in

this administrative area.

Implemented: 02/23/2011

Revised: 04/15/2011

Windsor C-1 School District, Imperial, Missouri

FILE: EFEA

BASIC

DISTRIBUTION OF NON-COMMERCIAL FOODS

(Shared Foods in the School Environment)

In the interest of providing a safe and healthy environment, the Windsor C-1 School District prohibits the consumption of shared foods during the school day. Some medical conditions and allergic reactions to food ingredients pose a serious risk to student safety. This risk is higher when food ingredients are unknown or when appropriate food preparation conditions cannot be controlled. Therefore, only prepackaged foods with nutritional labeling may be brought to school for student consumption. Home-prepared foods are not permitted or sold to students during the school day. This policy does not pertain to students’ individual lunches and /or snacks brought from home for personal consumption.

Student Allergy Prevention and Response Policy

Parent Signature Page

Please sign on the line below acknowledging that you have read and understand the Windsor C-1 School District’s Student Allergy Prevention and Response Policy. If you have any questions, please contact the principal or school nurse.

___________________________________________ _____________________

Parent Signature Date

___________________________________________

Parent Printed Name

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Page 1

For Office Use Only: JHCF-AF1.WSR (11/10)

For Office Use Only: JHCF-AF1.WSR (11/10)

Page 2

Page 1

For Office Use Only: JHCF-AF4.WSR (11/10)

Page 2

For Office Use Only: JHCF-AF4.WSR (11/10)

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