A u t h o r i z a t i o n  f o r  S t u d e n t P o s s e s s i o n  a n d
U s e  o f a n  E p i n e p h r i n e  A u t o i n j e c t o r

5330 F4

A completed form must be provided to the school principal and/or nurse before the student may possess and use an epinephrine autoinjector to treat anaphylaxis in school.

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Student Name 	Address

This section must be completed and signed by the student’s parent or guardian.

As the Parent/Guardian of this student, I authorize my child to possess and use an epinephrine autoinjector, as prescribed, at the school and any activity, event, or program sponsored by or in which the student’s school in a participant. I understand that a school employee will immediately request assistance from an emergency medical service provider if this medication is administered. I will provide a backup dose of the medication to the school principal or nurse
as required by law.

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Parent/Guardian Signature 	Date

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Parent/Guardian Name 	Parent/Guardian Emergency Telephone Number

This section must be completed and signed by the medication prescriber.

_______     ____     ____     ____     ____     ____     ____     ___     ______     ____     ____     ____     ____     ____     ____     ___     ____ Name and dosage of medication

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Date medication administration begins 	Date medication administration ends (if known)

_______     ____     ____     ____     ____     ____     ____     ___     ______     ____     ____     ____     ____     ____     ____     ___     ____ Circumstances for use of the epinephrine autoinjector

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Procedures for school employees if the student is unable to administer the medication or if it does not produce the expected relief

Possible severe adverse reactions:

_______     ____     ____     ____     ____     ____     ____     ___     ______     ____     ____     ____     ____     ____     ____     ___     ____ To the student for which it is prescribed (that should be reported to the prescriber)

_______     ____     ____     ____     ____     ____     ____     ___     ______     ____     ____     ____     ____     ____     ____     ___     ____ To a student for which it is not prescribed who receives a dose

_______     ____     ____     ____     ____     ____     ____     ___     ______     ____     ____     ____     ____     ____     ____     ___     ____ Special instructions

As the prescriber, I have determined that this student is capable of possessing and using this autoinjector appropriately and have provided the student with training in the proper use of the autoinjector.

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Prescriber Signature 	Date

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Prescriber Name 	Prescriber Emergency Telephone Number

Ohio Department of Health
In accordance with ORC 3313.718/3313.141
Developed in collaboration with the Ohio Association of School Nurses. HEA 4222 3/07

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