FormsParents & StudentsHealth → Emergency Care for the Management of a Student With a Diagnosis of Anaphylaxis

Emergency Care for the Management of a Student With a Diagnosis of Anaphylaxis

Release and Indemnification Agreement for Epinephrine Auto Injector

About this Form

Form number: 525-14

Audience:  Parents/Guardians, School Staff

Last revised: August 2023

Related Forms

Form 525-12 - Authorization to Provide Medically Prescribed Treatment

Form 525-13 - Authorization to Administer Prescribed Medication

INFORMATION: The authorized prescriber prescribed Epinephrine Auto Injector WILL NOT BE ADMINISTERED IN SCHOOL OR DURING SCHOOL sponsored activities without a parent/guardian signed authorization and waiver and an authorized prescriber's order/authorization for students with a known diagnosis of anaphylaxis.

The rescue squad (911) will always be called when an epinephrine auto injector is administered, whether or not the student manifests any symptoms of anaphylaxis.

In accordance with Maryland State Regulations, the epinephrine auto injector may be administered by unlicensed staff (DHHS School Health Room Technician or MCPS employee) that are trained by the School Community Health Nurse (SCHN). Unlicensed staff are not allowed to wait for the appearance and observe for the development of symptoms for students with an authorized prescriber's order to administer the epinephrine auto injector.

Adobe PDF Emergency Care for the Management of a Student With a Diagnosis of Anaphylaxis
Release and Indemnification Agreement for Epinephrine Auto Injector
84 KEnglish
Adobe PDF Atención de Emergencia para Estudiantes con Diagnóstico de Anafilaxia59 KSpanish
Adobe PDF Soins d’Urgence pour la Gestion d’un Élève60 KFrench
Adobe PDF Chăm Sóc Khẩn Cấp để Trông Nom Một Học Sinh Được Chẩn Đoán Có Phản Ứng Quá Mẫn Tính141 KVietnamese
Adobe PDF 對突發嚴重過敏反應的學生的緊急護理143 KChinese
Adobe PDF 아나필락시스 진단을 받은 학생의 관리를 위한 응급처치96 KKorean
Adobe PDF አናፍሌክስስ ላለበት/ባት ተማሪ የድንገተኛ አንክብካቤ አሰጣጥ77 KAmharic
Adobe PDF uidados Emergenciais para o Manejo de uma Aluno com Diagnóstico de Anafilaxia60 KPortuguese

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat