Epinephrine Administration Reporting Form

Following administration of Epinephrine to students or staff, please complete this form. While not mandatory, completion of this form will allow the Center to monitor the incidence and details of Epinephrine administration in schools. This information will be used to plan programs and training, create educational resources, and provide support to school health professionals in the care of students/staff.

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* 1. School District Name

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* 3. Type of School

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* 4. Level

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* 5. Date of Occurrence

Date
Time

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* 6. Epinephrine given

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