Phone:
Phone:
Phone:
Name/Relationship:
I hereby authorize the school district staff members to take whatever action in their judgment may be necessary in supplying emergency medical
services consistent with this plan, including the administration of medication to my child. I understand that the Local Governmental and Govern-
mental Employees Tort Immunity Act protects staff members from liability arising from actions consistent with this plan. I also hereby authorize
the school district staff members to disclose my child’s protected health information to chaperones and other non-employee volunteers at the
school or at school events and field trips to the extent necessary for the protection, prevention of an allergic reaction, or emergency treatment of
my child and for the implementation of this plan.
Name/Relationship:
Parent/Grardian Signature:
LICENSED HEALTHCARE
PROVIDER SIGNATURE: Phone:
(REQUIRED)
Date:
Date:
ILLINOIS FOOD ALLERGY EMERGENCY ACTION PLAN
AND TREATMENT AUTHORIZATION
ANY SEVERE SYMPTOMS AFTER SUSPECTED
INGESTION:
LUNG: Short of breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy, confused
THROAT: Tight, hoarse, trouble breathing/swallowing
MOUTH: Obstructive swelling (tongue)
Or COMBINATION of symptoms from dierent body areas:
SKIN: Hives, itchy rashes, swelling
GUT: Vomiting, crampy pain
EPINEPHRINE (BRAND AND DOSE):
ANTIHISTAMINE (BRAND AND DOSE):
OTHER (E.G., INHALER-BRONCHODILATOR IF ASTHMA):
CONTACTS: Call 911 Rescue Squad:
Parent/Guardian:
MILD SYMPTOMS ONLY:
MOUTH: Itchy mouth
SKIN: A few hives around mouth/face, mild itch
GUT: Vomiting, crampy pain
If checked, give epinephrine for ANY symptoms if the allergen was likely eaten.
If checked, give epinephrine before symptoms if the allergen was definitely eaten.
INJECT EPINEPHRINE IMMEDIATELY
• Call 911
• Begin monitoring (see below)
• Antihistamine
• Inhaler (bronchodilator) if asthma
*Inhalers/bronchodilators and antihistamines are not
to be depended upon to treat a severe reaction
(anaphylaxis) use Epinephrine*
**When in doubt, use epinephrine. Symptoms can
rapidly become more severe.**
GIVE ANTIHISTAMINE
• Stay with child, alert health care professionals and parent.
IF SYMPTOMS PROGRESS (see above), INJECT EPINEPHRINE
D.O.B:
GRADE:
NAME:
TEACHER:
CHILD’S
PHOTOGRAPH
ALLERGY TO:
ASTHMA: YES (HIGHER RISK FOR A SEVERE REACTION)
Student may self-carry epinephrine Student may self-administer epinephrine
NO WEIGHT: lbs
MONITORING: Stay with the child. Tell rescue squad epinephrine was given. A second dose of epinephrine can be
given a few minutes or more after the first if symptoms persist or recur. For a severe reaction, consider keeping
child lying on back with legs raised. Treat child even if parents cannot be reached.
MEDICATIONS/DOSES
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