Southington Public Schools

Southington School Health Services Southington, Connecticut

Authorization for EpiPen/Benadryl Administration by School Personnel

Connecticut State Law requires a written order from a MD, DDS, PA, or APRN and a parent or legal guardian’s authorization for both prescription and non-prescription medications. All medications shall be delivered to the school by the parent, guardian, or other responsible adult. The medication must be stored in the original labeled container as dispensed from the pharmacy. No more than a forty-five-day supply of medication may be left at school.

Name of Student: DOB: Grade: ___ Known Allergies: ______If patient ingests or thinks he/she has ingested the above named food or has been stung by above named insect:

Please note desired order(s): Circle desired EpiPen dosage: ______Observe patient for symptoms of anaphylaxis*** ______Administer Benadryl ______tsp. Swish and swallow ______Administer epinephrine before symptoms occur - EpiPen 0.15 mg. 0.3 mg ______Administer epinephrine if symptoms occur - EpiPen 0.15 mg. 0.3 mg ______Administer ______9-1-1 will be called for any patient with anaphylactic symptoms or EpiPen administration.

***Symptoms of Anaphylaxis: Chest tightness, cough, shortness of breath, wheezing, tightness in throat, difficulty swallowing, hoarseness, swelling of lips, tongue or throat, itching mouth or skin, hives or swelling, stomach cramps, vomiting or diarrhea, dizziness or fainting Special Instructions: ______Dates to be Administered: From: To: ______Signature: (Physician or Authorized Prescriber) Address: Phone: Date: ______  Authorization of Parent or Legal Guardian

I understand the above information and hereby give my permission for school personnel to administer to my child the medication ordered above by his/her MD, DDS, PA, or APRN. I realize that this medication will be destroyed if it is not picked up within one week following termination of the order or by the last day of school, whichever comes first.

Signature of Parent/Legal Guardian: ______Date: Phone: ______Medauth2,11/99, 10/05, 11/07