DEPAUL CATHOLIC

DEPAULCATHOLICHSIGH CHOOL1512 Alps Road, Wayne, NJ 07470-3695973.694.3702 Fax: 973.633.5381 http://www.depaulcatholic.orgDear Parent/Guardian:Enclosed is the necessary paperwork to be completed by both physician and parent for this schoolyear 2021-2022.Please fill in completely and return to the school's health office as soon as possible. Thispaperwork is required so that your child can be cared for properly and so that he/she may selfadminister their Epi-Pen (epinephrine) in school.*If this does not pertain to your child, please fill in only the second page and return it to the healthoffice and no further paperwork from this packet is required,If you have any concerns or questions please feel free to contact the school's nurse at school 973694-3702, Ext. 270; fax 973-694-6232. Thank you for your anticipated cooperation in this matter.School Health OfficeThank youHealth Officenurse@dpchs.org(P) 973-694-3702 Ext 270(F) 973-694-6232Large Enough to Challenge, Small Enough to CareACCREDITED BY: Middle States Association of Colleges and Schools and AdvancED Accredited/SACS

DEPAULCATHOLICHSIGH CHOOL1512 Alps Road, Wayne, NJ 07470-3695973.694.3702 Fax: 973.633.5381 http://www.depaulcatholic.orgDear Parent /Guardian,We are updating our health records for this 2021-2022 school year. In your child'shealth records from the past, it states that your child had allergies and may need tocarry an epinephrine injection pen (Epi-Pen) for emergencies. Please indicate yourresponse by checking off the appropriate boxes and returning this form to thenurse's office as soon as possible. We are trying to reduce unnecessary paperworkfor you and our health office. Thank you in advance for yourcooperation.Child's NameAllergy History of: My child no longer has this diagnosis and does not need any medication,including Benadryl and epinephrine. (No further paperwork needs to becompleted from this packet.)My child never had this diagnosis. (No further paperwork needs to becompleted from this packet.)My child must use an Epi-Pen and will carry the pen with him/her.My child must use an Epi-Pen and will keep one available in the nurse’soffice.Other comments:Parent/Guardian Name: Date:Parent/Guardian Signature:Large Enough to Challenge, Small Enough to CareACCREDITED BY: Middle States Association of Colleges and Schools and AdvancED Accredited/SACS

DEPAULCATHOLICHSIGH CHOOL1512 Alps Road, Wayne, NJ 07470-3695973.694.3702 Fax: 973.633.5381 http://www.depaulcatholic.orgTo:Parent /Guardian,Re:2021-2022 Food Allergy & Anaphylaxis Emergency Care PlanPlease download, review, and sign the FARE (Food Allergy & AnaphylaxisEmergency Care Plan) form at .pdf. Please complete the entire form, obtain required signatures, and return toyour child's school. (For your convenience, the subsequent two pages are copies ofthat form.)The FARE form addresses: Severe SymptomsMild SymptomsMedication/DosesDirections -Epipen Auto InjectorDirections - AdrenaclickDirections -AUVI-QIn addition, please sign and return this memo along with the FARE form ( whichrequires parent and physician signatures).As per parent/guardian of the student listed below, I understand that if theprocedures as specified in N,J.S.A. 18A:40-12.6 are followed, the district or nonpublic school shall have no liability as a result of any injury arising from theadministration of the epinephrine via a pre-filled auto-injector mechanism to thepupil and that the parents or guardians shall indemnify and hold harmless thedistrict, non-public school, and its employees or agents against any claims arisingout of the administration of the epinephrine via a pre-filled ꞏauto-injectormechanism to the pupil.Student's Name: School: DePaul Catholic HSPhysician Signature: Phone:Parent/Guardian Signature: Phone:Large Enough to Challenge, Small Enough to CareACCREDITED BY: Middle States Association of Colleges and Schools and AdvancED Accredited/SACS

Name: D.O.B.:Allergic to:Weight: lbs. Asthma:PLACEPICTUREHERE Yes (higher risk for a severe reaction) NoNOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.Extremely reactive to the following allergens:THEREFORE: If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms. If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.MILD SYMPTOMSFOR ANY OF THE FOLLOWING:SEVERE SYMPTOMSLUNGHEARTPale or bluishShortness ofbreath, wheezing, skin, faintness,weak pulse,repetitive coughdizzinessSKINMany hives overbody, widespreadrednessGUTRepetitivevomiting, severediarrheaTHROATTight or hoarsethroat, troublebreathing orswallowingOTHERFeelingsomething bad isabout to happen,anxiety, confusionMOUTHSignificantswelling of thetongue or lipsOR ACOMBINATIONof symptomsfrom differentbody areas.INJECT EPINEPHRINE IMMEDIATELY.2.Call 911. Tell emergency dispatcher the person is havinganaphylaxis and may need epinephrine when emergency respondersarrive.Consider giving additional medications following epinephrine:»»AntihistamineInhaler (bronchodilator) if wheezingMOUTHItchy mouthSKINA few hives,mild itchGUTMildnausea ordiscomfortFOR MILD SYMPTOMS FROM MORE THAN ONESYSTEM AREA, GIVE EPINEPHRINE.FOR MILD SYMPTOMS FROM A SINGLE SYSTEMAREA, FOLLOW THE DIRECTIONS BELOW:1. Antihistamines may be given, if ordered by ahealthcare provider.3. Watch closely for changes. If symptoms worsen,give epinephrine.MEDICATIONS/DOSESEpinephrine Brand or Generic:Epinephrine Dose: Lay the person flat, raise legs and keep warm. If breathing isdifficult or they are vomiting, let them sit up or lie on their side. If symptoms do not improve, or symptoms return, more doses ofepinephrine can be given about 5 minutes or more after the last dose. Alert emergency contacts. Transport patient to ER, even if symptoms resolve. Patient shouldremain in ER for at least 4 hours because symptoms may return.PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATUREItchy orrunny nose,sneezing2. Stay with the person; alert emergency contacts.1. NOSEDATE 0.1 mg IM 0.15 mg IM 0.3 mg IMAntihistamine Brand or Generic:Antihistamine Dose:Other (e.g., inhaler-bronchodilator if wheezing):PHYSICIAN/HCP AUTHORIZATION SIGNATUREFORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2020DATE

HOW TO USE AUVI-Q (EPINEPHRINE INJECTION, USP), KALEO1.2.3.4.Remove Auvi-Q from the outer case. Pull off red safety guard.Place black end of Auvi-Q against the middle of the outer thigh.Press firmly until you hear a click and hiss sound, and hold in place for 2 seconds.Call 911 and get emergency medical help right away.3HOW TO USE EPIPEN , EPIPEN JR (EPINEPHRINE) AUTO-INJECTOR AND EPINEPHRINE INJECTION (AUTHORIZEDGENERIC OF EPIPEN ), USP AUTO-INJECTOR, MYLAN AUTO-INJECTOR, MYLAN1.2.3.4.Remove the EpiPen or EpiPen Jr Auto-Injector from the clear carrier tube.Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. With your other hand,remove the blue safety release by pulling straight up.Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. Hold firmly in place for3 seconds (count slowly 1, 2, 3).Remove and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK ),USP AUTO-INJECTOR, AMNEAL PHARMACEUTICALS1.2.3.4.45Remove epinephrine auto-injector from its protective carrying case.Pull off both blue end caps: you will now see a red tip. Grasp the auto-injector in your fist with the red tip pointing downward.Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh. Press down hard andhold firmly against the thigh for approximately 10 seconds.Remove and massage the area for 10 seconds. Call 911 and get emergency medical help right away.HOW TO USE TEVA’S GENERIC EPIPEN (EPINEPHRINE INJECTION, USP) AUTO-INJECTOR,TEVA PHARMACEUTICAL INDUSTRIES1.2.3.4.5.HOW TO USE SYMJEPI (EPINEPHRINE INJECTION, USP)1.2.3.4.5.5Quickly twist the yellow or green cap off of the auto-injector in the direction of the “twist arrow” to remove it.Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. With your other hand, pull off theblue safety release.Place the orange tip against the middle of the outer thigh at a right angle to the thigh.Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. Hold firmly in place for 3seconds (count slowly 1, 2, 3).Remove and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.When ready to inject, pull off cap to expose needle. Do not put finger on top of the device.Hold SYMJEPI by finger grips only and slowly insert the needle into the thigh. SYMJEPI can be injected throughclothing if necessary.After needle is in thigh, push the plunger all the way down until it clicks and hold for 2 seconds.Remove the syringe and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.Once the injection has been administered, using one hand with fingers behind the needle slide safety guard over needle.2ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:1.Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer thigh. In case ofaccidental injection, go immediately to the nearest emergency room.2.If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.3.Epinephrine can be injected through clothing if needed.4.Call 911 immediately after injection.OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.EMERGENCY CONTACTS — CALL 911OTHER EMERGENCY CONTACTSRESCUE SQUAD:NAME/RELATIONSHIP: PHONE:DOCTOR: PHONE:NAME/RELATIONSHIP: PHONE:PARENT/GUARDIAN: PHONE:NAME/RELATIONSHIP: PHONE:FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2020