Walking Permission Slip

EARLY INTERVENTION EARLY CHILDHOOD SPECIAL EDUCATION MEDICAL PROTOCOLS

ALLERGIC REACTION PROTOCOL

Child’s Name: Birthdate: Parent/Guardian: Home Phone: Address: Work Phone: Additional Info: Cell Phone: Physician Treating Student for Allergies: Work Phone: Protocol Written By: Date:

Specific Instructions: If Stung by Insect: After Ingesting: After Exposure: For Mild Systems such as: a. Small localized rash or redness d. Nasal drip or congestion b. Mild itching at area of contact e. Intermittent sneezing c. Eye irritation, watering, red eyes Do the following: 1. Wash/rinse affected area thoroughly with running water. 2. Monitor student for signs of anaphylaxis under direct observation for 60 minutes 3. Advise parent of incident before returning student to class. If symptoms increase or if any signs (listed below) are present: a. Continuous sneezing, wheezing, or coughing i. Dizziness and/or fainting b. Shortness of breath or tightness of chest, difficulty in or j. Involuntary bowel or bladder emptying absence of breathing c. Itching, with or without hives, raised red rash in any area of k. Sense of impending disaster or approaching death the body d. Difficulty swallowing l. Rapid or weak pulse e. Swelling of eyes, lips, face, tongue, throat or elsewhere m. Skin flushing or extreme paleness f. Hoarseness n. Burning sensation, especially face or chest g. Sweating and anxiety o. Blueness around lips, inside lips, eyelids h. Nausea, abdominal pain, vomiting, or diarrhea p. Loss of consciousness Do the following: 1. If Epi-pen or other medication for allergic reaction has been provided by parent, give/use as directed per attached Medication Authorization Form. 2. Call 911 immediately. 3. Begin CPR for absent breathing/pulse. 4. Notify Parent. SIGNATURES: Parent: Date: Teacher: Date: Service Coordinator : Date: EI/ECSE Nurse: Date: This authorization expires on ______(not to exceed one year from the date of signature above). (Month/Day/Year) ______For Office Use: Copies To: Parent EI/ECSE Nurse Transportation Office Physician EI/ECSE Office Other ______EI/ECSE Forms 10-2006