Glucagon Administration Reporting Form

Following administration of Glucagon to students or staff, please complete this reporting form. While not mandatory, completion of this form will allow the Center to monitor the incidence and details of Glucagon 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. Glucagon administered

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