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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: June 2017

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.

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Release and Indemnification Agreement for Epinephrine Auto Injector
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