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AUTHORIZATION FOR THE POSSESSION AND USE OF EPINEPHRINE AUTOINJECTOR
(EpiPen)
NEW FORM MUST BE SUBMITTED EACH SCHOOL YEARStudent Name: ___ Date: ___
Address: ___
Name of Medication
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How to fill out epinephrine autoinjector administration form
How to fill out epinephrine autoinjector administration form
01
Start by ensuring the patient's information is filled out on the form, including name, date of birth, and any allergies they have.
02
Next, document the reason for administering the epinephrine autoinjector, such as an allergic reaction or anaphylaxis.
03
Record the time and date the injection was given, as well as the dosage administered.
04
Have a healthcare provider or witness sign the form to verify that the medication was administered correctly.
05
Keep a copy of the completed form with the patient's medical records for future reference.
Who needs epinephrine autoinjector administration form?
01
Individuals who have been prescribed an epinephrine autoinjector for severe allergic reactions or anaphylaxis.
02
Schools, daycare centers, and other institutions where individuals may require emergency treatment for allergies.
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What is epinephrine autoinjector administration form?
The epinephrine autoinjector administration form is a document used to report the administration of an epinephrine autoinjector, typically in response to an anaphylactic reaction.
Who is required to file epinephrine autoinjector administration form?
Individuals or entities such as schools, camps, and workplaces that administer an epinephrine autoinjector must file the administration form.
How to fill out epinephrine autoinjector administration form?
To fill out the epinephrine autoinjector administration form, complete sections including the date and time of administration, the patient's details, the dose administered, and the signature of the person who administered it.
What is the purpose of epinephrine autoinjector administration form?
The purpose of the epinephrine autoinjector administration form is to document the use of the device and ensure proper reporting and follow-up care after an anaphylactic incident.
What information must be reported on epinephrine autoinjector administration form?
The report must include the patient's name, time and date of administration, dosage given, reason for administration, and the name of the person administering the autoinjector.
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