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OCDSB 616 - Severe Life-Threat Allergy Proto Reg FULL VSNSevere, Life Threatening Allergy Protocol Registration (References: P.108.SCO and PR.548.SCO) NOTE: Please type and submit the original, signed copy to your child’s school principal in a timely manner. In the case of ongoing serious medical conditions (such as but not limited to severe, life-threatening allergies, diabetes, epilepsy, heart condition, asthma), this authorization will terminate on August 31 of each school year. Please ensure to notify the principal if the prescription changes or expires. This authorization may be cancelled upon receipt of written notification to the principal. School Name: Date: Principal’s Name: Home Form Teacher’s Name: Student’s Name: Student No.: Year/Grade: Location of Auto-Injector on Student: Pick-up/Drop-off Bus Route Numbers: Transportation Address: STUDENT’S PHOTO: PLEASE ATTACH A RECENT PHOTO OF STUDENT TO FORM ALLERGIES: Anaphylactic reaction (life-threatening) to (specify): SYMPTOMS An anaphylactic reaction can begin within seconds or exposure or after several hours. Any combination of the following symptoms may signal the onset of a reaction. Please indicate symptoms to watch for: Hives Itching (on any part of the body) Swelling (of any body parts, especially eyes, lips, face, tongue) Red watery eyes Runny nose Vomiting Diarrhea Stomach cramps Change of voice Coughing (could sound like throat clearing) W heezing Throat tightness or closing Difficulty swallowing Difficulty breathing Sense of doom Dizziness Fainting or loss of consciousness Change of colour Other OCDSB 616 School Operations (June 2014) Confidential W hen Complete Page 1 of 4 Distribution: OSR WARNING: •Symptoms do not always occur in the same order or intensity, even in the same individuals. •Time from onset of first symptoms to death can be as little as a few minutes if the reaction is not treated. •Even when symptoms have subsided after initial treatment, they can return as much as eight hours after exposure. GENERAL COURSE OF ACTION Administer Medication and Call Ambulance Even if Parents/Guardians Cannot be Reached If there is ANY suspicion that the student may have been exposed to his/her life-threatening allergies or is displaying any of the above symptoms: •Use Auto-Injector IMMEDIATELY – Storage Locations: (It is highly recommended that each student carry an EpiPen® at all times, with back-up kept in the office or accessible location.) •The student should rest quietly. •Send a runner to immediately notify the principal or designate to call Emergency 911 and have Auto-Injector (if NOT carried by the student) delivered to the room immediately by an adult. •Do not send the child to the office. (Time is of the essence and supervision essential.) •The student must be transported immediately to the hospital with extra Auto-Injectors to be administered approximately 10/15 minutes later if needed. •Monitor the student until the ambulance arrives. •Have the student ready to go. •Call parents/guardians: Parent/Guardian Name: Parent/Guardian Contact Number(s): OR Parent/Guardian Name: Parent/Guardian Contact Number(s): OR Emergency Contact Name: Emergency Contact Number(s): SPECIFIC COURSE OF ACTION: (To be completed by Allergist/Physician) Tastes or ingests allergic substance: Skin contact with allergen: OCDSB 616 School Operations (June 2014) Confidential W hen Complete Page 2 of 4 Distribution: OSR Smells an allergen substance: Other: Instructions re Ambulance: Allergist/Physician’s Name: Telephone: Allergist/Physician’s Signature: Date: PARENT(S) / GUARDIAN(S) RESPONSIBILITY: It is the responsibility of the parent(s)/guardian(s): •To inform the principal of a pupil’s medical needs if medication will be required during school hours; •To inform the program supervisors of other OCDSB programs such as Lighthouse, or OCDSB facilitated programs such as Day Care, of a pupil’s medical needs if medication will be required during their program hours; •To request assistance of the school and discuss procedures that may be required; •To ensure that accurate and up-to-date telephone contacts are available to the school; •To submit all required documentation, such as a completed OCDSB 405: Emergency Use of an auto-injector and OCDSB 616: Severe, Life-Threatening Allergy Protocol Registration to the principal of the school. Note: No medication may be left at school without authorization. PARENT/GUARDIAN AUTHORIZATION RE: CONSENT TO RELEASE I/we give consent for school staff to use and share the information provided in this form as required to attend to the education, health and safety of myself/my child. This may include: •The pertinent information contained within will be shared with the Ottawa Student Transportation Authority and applicable contracted bus operators (including your child’s bus driver where appropriate); •Posting of the student’s photograph (physical and/or electronic) in the school so that all staff, volunteers and visitors are aware of the medical condition; •And any such other circumstances that may be necessary to ensure the health and safety of your child. Parent/Guardian Signature (or student if 18 years or older): Date: PARENT/GUARDIAN AUTHORIZATION RE: CONSENT TO TRANSFER TO HOSPITAL I/we give consent for my child to be transported to a hospital if deemed necessary by school staff, and if necessary, a staff member may also accompany my child during transport. Note: The principal shall decide if an ambulance is to be called. Parent/Guardian Signature (or student if 18 years or older): OCDSB 616 School Operations (June 2014) Confidential W hen Complete Page 3 of 4 Distribution: OSR Date: The personal information on this form is collected under the authority of the Education Act and will only be used to record parental authorization for the self-administration by the student of the named medication. Access to this information will be limited to those who have an administrative need, to the student to whom the information relates and the parent(s)/guardian (s) of a student who is under 18 years of age. If you wish to review this inf ormation or have questions regarding its collection, please contact your school principal. The information collected will be protected against theft, loss and unauthorized use or disclosure. THIS FORM MUST BE COMPLETED IN A TIMELY MANNER, INCLUDE ORIGINAL SIGNATURE(S) AND SUBMITTED TO THE SCHOOL PRINCIPAL. PRINCIPAL’S ACKNOWLEDGEMENT I have reviewed the information provided in this form, obtained clarification if required, and acknowledge its receipt. Principal’s Signature: Date: A copy of this form must be kept with the Auto-Injector and in the student’s classrooms, the lunchroom, and in other central locations where information regarding anaphylactic students is available. Share this completed form with all of the student’s teachers. Use the review of this form as an opportunity to discuss the implementation of the guidelines with the parent(s)/guardian(s). Place a copy in the student’s OSR folder. OCDSB 616 School Operations (June 2014) Confidential W hen Complete Page 4 of 4 Distribution: OSR