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Y.A.L.E. School
Food Allergy Questionnaire
School Year: ______________
Student’s Name:
Teacher:
Date of Birth:

Parent/Guardian’s Name:
_________

Parent/Guardian’s Name:
________

Please list the specific food allergies and the symptoms experienced:
1. Is your child allergic to touching a food listed above? Yes or No Food: 2. Is your child allergic to smelling a food listed above? Yes or No Food: 3. Does your child see an allergist? Yes or No Name of allergist: _______________________________ Phone #: ________________ 4. Has your child’s physician prescribed an Epi-Pen for your child? Yes or No 5. How many times has your child required the use of an Epi-Pen? 6. Has your child ever been treated in the emergency room or hospitalized due to a food allergy? Please explain: 7. What medications have you given to your child to reverse his/her symptoms related to food allergies? Please list all: 8. Does your child know to refuse to accept food from another child? Yes or No 9. Does your child need to sit away from students that have peanuts or peanut butter for lunch? Yes or No 10. Are you willing to provide an allergen free “treat” in a container to freeze to be kept at school for classroom celebrations? Y.A.L.E. School
Permission for Benadryl and/or Epinephrine by the School Nurse
School Year ________________

ANTIHISTIMINE ORDER:

Upon exposure or suspected exposure to the allergen listed above, please observe the student for
the development of the following symptoms:
If the symptoms listed above do develop, administer the following antihistamine dosage. Check one: EPINEPHRINE ORDER:
If the student develops a more severe reaction including throat or chest tightness, horse voice,
difficult swallowing or breathing, edema of face, throat, tongue, severe hives and itching, dizziness,
unconsciousness or cardiovascular problems or other symptoms indicating an anaphylactic reaction,
administer:

Check one:

Please indicate if you give permission for a second dose of epinephrine to be given if the student
does not respond to the first dose.
I hereby give permission for the school nurse to administer the above medication (s) to my child. I shall provide the medication in its original container, properly labeled from the pharmacy/store. I release the Y.A.L.E. School and its employees from any liability concerning the administration of such medication to my child. Parent’s Signature: Y.A.L.E. School
Medication Permission for Administration of Epinephrine by a Delegate
School Year: ______________
**Please note that a delegate may NOT give an antihistamine, therefore the physician’s order must note the specific symptoms and/or events (I.E. ingestion of a peanut) as to when the delegate should administer the epinephrine** Check off the appropriate times the delegate should administer epinephrine in the dose indicated below. (This MUST be completed for the delegate order to be in effect). ___ If a food allergen has been ingested, but no symptoms. Name the allergen (s) If stung or bitten by an insect, by no symptoms. Name the allergen (s) Mouth: Itching, tingling, or swelling of lips, tongue and mouth Throat: Tightening of throat, hoarseness, hacking cough Lung: Shortness of breath, repetitive coughing, wheezing Heart: Thready pulse, passing out, fainting, paleness, blueness Skin: Hives, itchy rash, swelling on the face or extremities Gut: Nausea, abdominal cramps, vomiting, diarrhea * If any of the above checked situations occur with the student named above, give the following injection of epinephrine intramuscularly in the thigh: ___ Epi-Pen Jr. 0.15mg Possible side effects: ____________________________________________________ After the administration of epinephrine, the delegate will call 911, monitor the student and perform CPR if indicated and certified. I hereby give permission for my child’s delegate(s) to administer the above medication to my child named above. I shall provide this medication in its original container, properly labeled from the pharmacy/store. I release the Y.A.L.E. School and its employees from any liability concerning the administration of such medication to my child. Parent’s Signature: Y.A.L.E. School
Parent Permission Form for Delegating Epinephrine Administration and for Subsequent Emergency
School Year: ______________
Student’s Name:

Role of Parent/Guardian:

The parent must provide the school nurse with a written medication order from the child’s physician or advanced practice nurse for the administration of epinephrine for an allergic reaction. The medication order must be cosigned by the parent. The parent must provide the school nurse with a properly labeled epinephrine auto injector and is responsible to promptly replace auto injectors after their use or upon expiration.
Parent/Guardian Statement:
I give permission for the school nurse or her trained delegate(s) to administer epinephrine by auto
injector to my child as per the medication order for the treatment of anaphylaxis as identified by my
child’s doctor. I understand that there are times during the school day when the school nurse may
not be available. In this situation, a trained delegate would administer the epinephrine. I
acknowledge that if the established protocols are followed, the school district and its employees shall
have no liability as a result of any injury arising from the administration of epinephrine to my child. I
indemnify and hold harmless the district and its employees or agents against any claim arising out of
the administration of the epinephrine to my child.
The following employee(s) are trained as delegates for my child: ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________
I also understand that this permission is effective for this school year only, and must be renewed for
each subsequent school year. I understand that we are to supply a current auto injector of the
prescribed dose of epinephrine and are responsible for replacing it when it has expired.
I give my permission for my child to receive follow-up medical treatment as deemed necessary at an
emergency health care facility.
The school nurse may share this information with school staff as necessary.
Parent’s Signature:
Y.A.L.E .School
Permission for SELF ADMINSTRATION of Benedryl and/or Epinephrine
School Year: ______________

ANTIHISTAMINE ORDER:
Upon exposure or suspected exposure to the allergen listed above,

has permission to SELF ADMINISTER one dose of the following medication in accordance with
P.L.2007,c57.


Benedryl (dosage)
Other antihistamine (name and dosage)
***In accordance with P.L.2007,c57, a student who can self administer can self administer one dose of antihistamine if ordered by student’s physician. The medication MUST be carried by the student and MUST be in a single packet dose. Student does NOT have permission to self administer one dose of antihistamine.

EPINEPHERINE ORDER:
Upon exposure or suspected exposure to the allergen listed above, I certify that this student has been
trained in the use of an epinephrine auto-injector and is capable of self administration of this
medication in the absence of a school nurse or delegate.
Epi-Pen Jr. 0.15mg
Epi-PEN 0.3mg

Physician Signature:

***This portion to be completed by the parent or guardian.
I give my child permission to self-administer the above medications (s) in the absence of the school
nurse or delegate. I will provide (please check)
A single dose packet of the prescribed antihistamine listed above. I agree to replace medication upon use or expiration. I release the Y.A.L.E. School and its employees from any liability concerning the self-administration of such medications. Parent’s Signature:

Source: http://www.yaleschool.com/wp-content/uploads/2012/09/Allergy-packet-for-parent-2012.pdf