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Name: ______________________________________________________________ Grade: _________ Age: _________ Homeroom Teacher/Room: ___________________________________________________________________________Parent/Guardian Name: _______________________________________________Home Phone: ___________________Address: ___________________________________________________________ Work Phone: ____________________Parent/Guardian Name: _______________________________________________Home Phone: ___________________Address: ___________________________________________________________ Work Phone: ____________________Emergency Contact: Name_________________________________ Relationship ____________ Phone_______________Emergency Contact: Name_________________________________ Relationship ____________Phone_______________Physician Treating Student for Anaphylaxis: _______________________________________ Phone: _________________Other Physician: _________________________________________________________ Phone: _____________________My child’s anaphylaxis (severe allergic reactions) triggers are:? Peanuts ? Tree Nuts ? Milk ? Dairy ? Fish ? Shellfish ? Eggs ? Trees/Weeds ? Insects ? Medications ? Latex ? Other: ______________________________________________________________My child’s anaphylaxis symptoms are usually:? Swelling (eyes, lips, face, tongue) ? Difficulty breathing or swallowing ? Coughing or choking ? Cold, clammy, sweaty skin ? Dizziness, confusion, fainting or loss of consciousness ? Flushed face or body? Stomach cramps, diarrhea, vomiting ? Unknown ? Other: ______________________________________________________________________________________Only a few symptoms may be present. Severity of symptoms can change quickly.*Some symptoms can be life-threatening.Emergency Action Steps - DO NOT HESITATE TO GIVE EPINEPHRINE!Inject Epinephrine: Check One: ? EpiPen Jr. 0.15 mg ? EpiPen 0.3 mg ? Twinject 0.15mg ? Twinject 0.3 mg ? Auvi-Q 0.15mg ? Auvi-Q 0.3mg ? Other medication/dose/route (Antihistamine): _____________________Call 911 (before calling emergency contact)Call Emergency Contact Physicians Signature: ____________________________ ______________________Date: ________________________Physicians Printed Name: _________________________ ___________________Phone number: ___________________Parent and/or Legal Guardian: As the parent/legal guardian I hereby request and authorize the school nurse, health aide, or other school personnel to administer the medical procedures authorized by the physician named above to the Student. I agree to furnish all medications or other items necessary for the administration of the services. I agree to notify the School Health Office immediately if there are any changes in the Student’s medical condition or physician’s orders that impact the School’s responsibilities to the Student or that may impact the Student during the school day. Signing this form shall release the Higley Unified School District and its employees from liability of any nature that might result from this plan of action. I also acknowledge that the emergency plan of action will most likely be administered by trained, unlicensed Higley Unified School District personnel.Parent/Guardian Signature ____________________________ _________________Date: _________________________Severe Allergic Reaction (Anaphylaxis) Bus PlanStudent Name: _________________________________ Teacher: __________________________ Year: ____________Route: ____________________________________________________________________________________________Signs that may be present: Check all that apply:? Itching and Swelling of Lips ? Swelling of Tongue or Mouth ? Tightness of Throat ? Hacking? Cough or Wheezing ? Hives ? Itching ? Nausea or Vomiting ? Fainting? Other: _________________________________________________________________________________________Call 911: Let them know you have a child with a severe allergic reactionAdminister epinephrine device to outer thigh (if you have been trained to do so)Follow device instructionsSwing and jab firmly into outer thigh until Auto-Injector functionsHold in place and count to 10Document time epinephrine was administeredGive injector to EMS personnelLocation of Epinephrine Device: _______________________________________________________________Monitor child closely, reassure other students on the busIf breathing stops Start CPR!Emergency Contacts:Name: ______________________________________________ Relationship: _________________________________ Telephone: Home: _______________________ Work: ______________________ Cell: __________________________Name: ______________________________________________ Relationship: _________________________________ Telephone: Home: _______________________ Work: ______________________ Cell: __________________________Parent/Guardian Signature ____________________________ _________________Date: _________________________Nurse/Health Aide Signature ____________________________ ______________Date: __________________________Epinephrine Auto Injector DevicesEpiPen?Remove the EpiPen Auto-Injector from the plastic carrying case.Pull off the blue safety release cap.Swing and firmly push orange tip against mid-outer thigh.Hold for approximately 10 seconds.Remove and massage the area for 10 seconds.Auvi-QTMRemove the outer case of Auvi-Q. This will automatically activate the voice instructions.Pull off red safety guard.Place black end against mid-outer thigh.Press firmly and hold for 5 seconds.Remove from thigh.Adrenaclick? IAdrenaclicK?Remove the outer case.Remove grey caps labeled "1" and "2".Place red rounded tip against mid-outer thigh.Press down hard until needle penetrates.Hold for 10 seconds. Remove from thigh.Diet Order Form - AnaphylaxisSponsors of child nutrition programs may, at their discretion, make substitutions for individuals who are not “handicapped,” as defined in 7 CFR 15b.3 (i), but who are unable to consume a food item because of medical or other special dietary needs. Such substitutions may be made only on a case-by-case basis and when supported by a statement signed by “a recognized medical authority.” In such cases, “recognized medical authority” includes physicians, physician assistants and nurse practitioners.For those non-handicapped participants, the supporting statement shall include:The identification of the medical or other special dietary needs which restricts the child’s dietThe food or foods to be omittedThe food or choice of foods that may be substitutedIn most cases, individuals who are overweight or who have elevated blood cholesterol do not meet the definition of handicapped, and sponsors are not required to make meal substitutions for them. The special dietary need of non-handicapped participants may be managed within the normal program meal service when a well-planned variety of nutritious foods are available and when Offer Versus Serve is an option.Contact a School Health and Nutrition Program specialist for additional information (602) 542-8700MEDICAL STATEMENT FOR PARTICIPANTS WITH ALLERGIES/CHRONIC DISEASESOther medical personnel may complete this form (dietitian, speech pathologist, occupational therapist), but a physician or other recognized medical authority must sign in agreement as to what is written. For purposes of this program, a “recognized medical authority” means a licensed physician, nurse or physician’s assistant.Name of Participant: __________________________________Age: ________Agency: _________________________Parent/Guardian Name: ______________________________________________ Phone Number: __________________Site: ______________________________________________________________Phone Number: ___________________Food Allergy/Chronic Disease: ___________________________________________________________________________________________________________________________________________________________________________Foods to be Omitted and Substitutions: Please list specific foods to be omitted and suggest substitutions. You may use the back of this form or attach a sheet with additional information.Foods to be Omitted: ________________________________________________________________________________Suggested Substitutions: _____________________________________________________________________________Parent/Guardian Signature ____________________________ ________________ Date: _________________________Physicians Printed Name: ______________________________________________Phone Number: __________________Physicians Signature: ____________________________ ____________________ Date: __________________________Type of Health Services Needed At School - Medical DocumentationTO BE FILLED OUT AND SIGNED BY DOCTOR PROVIDING CAREDate: ____________Student Name:__________Date of Birth: ______________________________School Year:School Year: ____________________________ Please describe the Medical Diagnosis that will require health services support and/or supervision._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Type of services required Check All that Apply: (Please specify the needed care by checking the box below)? Medication Administration: ? Oral ? OTC ? Injection ? Epi-Pen ? Inhalation ? Ear/Eye Drops? Topical ? Per Nasogastric Tube ? Per Gastrostomy Tube ? Rectal ? Intra Nasal? Seizure Precautions: ? Vagus Nerve Stimulation w/Magnet? Catheterization: ? Clean Intermittent Cath ? External Catheter ? Care of Indwelling Catheter ? Feeding:? Oral ? Naso-Gastric Gastrostomy Tube Feeding or Venting ? Jejunostomy Feed ? Nutritional Screening ? Nutritional Assessment ? Oral-Motor Assessment ? Monitoring of Continuous ? Feed Naso-Gastric Tube Insertion? Naso-gastric Tube Removal Gastrostomy Tube Reinsertion ? Ventricular Peritoneal Shunt Monitoring? Oxygen Administration: ? Monitoring ? Nasal Cannula/Mask? Respiratory Assistance:? Postural Drainage ? Percussion ? Oral Suctioning ? Tracheostomy Suctioning ? Mechanical Vent Care? Diabetic Procedures:? BG monitoring ? Urine Ketones ? Insulin Administration ? Insulin Pump Bolus ? CHO counting/dosage calculation Glucagon? Toileting/Diapering ? Toilet Training? Dental Hygiene (Teeth Brushing)? Lifting/Positioning? Ostomy Care? Skin Care? Central Intravenous Catheter (PICC or Broviac): ? Site Monitoring ? Intravenous Medication AdminWhich services listed above need to be included in bus/transportation to school? Physicians Signature: ____________________________ ______________________Date: _________________________Physicians Printed Name: _________________________ ___________________Phone number: ___________________Purpose: Documentation for parents/guardians, the District and School Staff regarding health services delivered in a school setting in a way that maintains the health and safety of the student during the school day. ................
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