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Middlesex.k12.nj.us

Green Brook Family Medicine
EMERGENCY ADMINISTRATION OF EPI-PEN® (EPINEPHRINE) AT SCHOOL
April 10, 2012 Dear Parent /Guardian: New Jersey P.L. 2007, c57. And N.J.S.A. 18A:40-12.3-12.6 allows trained delegates for students who may require emergency administration of epinephrine by auto-injector for anaphylaxis when the school nurse is unavailable. The attached form is required for your child to receive epinephrine by auto-injector. This form gives the school district permission to allow for the school nurse and trained employees (delegates) of the school district to administer epinephrine via auto-injector when the school nurse is not physically present at the scene. It is in your student’s best interest to
allow your student to have at least one trained delegate at the school.

In addition the second part of this form allows your child to carry and self-administer epinephrine by auto-injector and diphenhydramine. I urge you to discuss this with your medical provider. We strongly encourage all middle and high school students to be trained to
carry and self-administer epinephrine by auto-injector and diphenhydramine.
Please
note that this may not be appropriate for students in elementary grade levels. Please return the form and two Epi-Pen® or Epi-Pen Jr® to the School Nurse as soon as possible. If you have any questions regarding these forms please do not hesitate to contact the School Nurse. Ronald M Frank, MD FAAFP School Medical Inspector AUTHORIZATION FOR ADMINISTRATION OF EPINEPHRINE AT SCHOOL
Student Name: ___________________________ DOB: _________________ Grade: _______________________ Emergency Contacts: (Name and Phone#’s):____________________________________________________________ ________________________________________________________________________________________________ I. Parental/Guardian Consent for Delegate Administration of Epinephrine Auto Injector
I hereby acknowledge my understanding that if the procedures outlines in P.L. 2007, c.57 and “TRAINING PROTOCOLS FOR THE
EMERGENCY ADMINISTRATION OF EPINEPHRINE “ issued by the NJ Department of Education are followed, the school district and
its employees or agents shall incur no liability as a result of any injury arising from the administration of a pre-filled single dose auto
injector containing epinephrine and the parent/guardian shall indemnify and hold harmless the school district and its employees or
agents against any claims arising from the administration of a pre-filled single dose auto injector containing epinephrine to the student.
The school nurse shall designate, in consultation with the Board of Education, additional employees of the school district to administer
epinephrine via auto-injector to my child for anaphylaxis or possible anaphylaxis when the school nurse is not physically presents at the
scene, as specified in P.L. 2007, c.57.
____ I approve having delegate(s) assigned for my child. I understand that a list of my student’s delegates is available for review in the
Nurse’s office.
____ I decline delegate administration of epinephrine for my child.
Parent/Guardian Name Signature Date
II.Parental/Guardian Consent for Student Self Administration of Epinephrine Auto Injector and Antihistamine:
____I request that my child be ALLOWED to carry the prescribed medication for self-administration in school and on
off-site school related activities pursuant to N.J.S.A.:18A:40-12.3-12.6. I give permission for my child to self-administer medication, as
prescribed on this form for the current school year as I consider him/her to be responsible and capable of transporting, storing and self-
administration of the medication. I understand that the school district, agents and its employees shall incur no liability as a result of any
condition or injury arising from the self-administration by the student of the medication prescribed on this form. I indemnify and hold
harmless the School District, its agents and employees against any claims arising out of self-administration or lack of administration of
this medication by the student.
____I do not allow my child to carry and self-administer epinephrine auto injector and antihistamine
Parent/Guardian Name Signature Date

III. Healthcare Provider’s Order
: (please check all applicable lines)
The above student has a potentially life threatening allergy that could result in anaphylaxis and
The Student’s potential triggers of Anaphylaxis are: _______________________________________________________________
The Student is an Asthmatic _________Yes __________No
The Student’s possible symptoms of Anaphylaxis are: _____________________________________________________________
Or __________possible symptoms are unknown at this time but student is at risk for future anaphylaxis.
The Student should sit at an Allergen Free Lunch Table: ______Yes ______No

In case of possible anaphylaxis administer: (Please DONOT prescribe TwinJet® products for school use)
____EpiPen® 0.3mg up to 2 doses as needed ____EpiPenJr® 0.15mg up to 2 doses as needed
*Please note our school standing orders allows a nurse to administer an equivalent dose of epinephrine via ampule and syringe

____School nurse
may administer a single oral dose of Diphenhydramine: ______________mg
____Student may self-administer epinephrine auto-injector as prescribed above. This student has been instructed in and is capable of
proper method of self-administration of epinephrine auto-injector. This student understands the purpose, appropriate method and
frequency of use of the medication prescribed above.
____Student may self-administer a single oral dose of Diphenhydramine: ______________mg
____This student is not approved to self-medicate with an epinephrine auto-injector or Oral Diphenhydramine
Physician’s Name Signature

Physician’s Office Stamp:


Approved by School Nurse (signature and date): ______________________________________________ Approved by School MD (signature and date): ________________________________________________

Source: http://www.middlesex.k12.nj.us/Portals/0/PDFs/HighSchool/Nurse/EPINEPHRINE.pdf

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