Rev 06.01.15 Copy: School File NOTE: This plan will be shared with all appropriate school district staff
Huron Valley Schools – Plan of Care (POC)
Allergy Management
Allergy Type: ___________________________________________________ Bus Route #: ___________
Student Name: _____________________________ School: ____________________ Grade: ___________
Signs of an allergic reaction include the following (Items that are checked are ones usually experienced by the
student when having a MINOR reaction.)
*Mouth: Itching and Swelling of the Lips Tongue Mouth
*Throat: Itching Sense of Tightness in the Throat Hacking Cough
Skin: Hives Itchy Rash Swelling about the Face or Extremities
Gut: Nausea Abdominal Cramps Vomiting Diarrhea
*Lung: Shortness of Breath Repetitive Coughing Wheezing
*Heart: Thready Pulse Fainting
*The severity of symptoms can quickly change. All above symptoms can potentially progress to a life-threatening
situation. If the student experiences only the above checked items suspect a minor reaction and:
Escort him/her to the main office immediately.
Administer Medication ______________________________________________________________
(Doctor, please identify the type of medication you wish to be administered)
Phone parents
Observe for any changes including development of more symptoms until the parent arrives.
If the suspect student ingested (ate) the allergen, or if the student experiences any of the following
symptoms: (Doctor, please identify the type of symptoms you would expect to see in a MAJOR
reaction)
_____________________ _____________________ _____________________ ____________________
he/she is having a MAJOR reaction
Inject one (1) Epi-Pen immediately (you may have to hold the student down)
Call 911 and monitor closely until help arrives
Call Parents: Home Phone: ____________________
Mother: __________________________Cell Phone: ___________________Work Phone:____________________
Father: __________________________Cell Phone: ___________________Work Phone:____________________
In the event that special accommodations are required, the school district may need up to five (5) school days to
comply with the request. It will be up to the parent and the physician to determine if the child shall attend school
during that time.
______________________________ __________ ___________________________________ ______________
PARENT SIGNATURE DATE PHYSICIAN SIGNATURE DATE
Physician Name ____________________________________
Physician Address___________________________________
Physician Phone ____________________________________
