Complete this incident report if epinephrine was administered on a school campus. If the incident occurred at a location other than on a school campus, please contact LifeReach at 1-844-548-4968.

This form collects general information regarding the anaphylactic incident. No personal health information is needed to answer questions. All questions purposely avoid collecting personal health information.

The report includes 52 multiple choice questions and will take approximately 10 minutes to complete. The report should be completed in its entirety in one session. The report cannot be saved and finished later.

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* 1. The incident occurred in a

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* 2. The name of the school is

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* 3. The school is located in what city

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* 4. The school is located in what state

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* 5. The school zip code is 

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* 6. The last name of the primary contact at the school is

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* 7. The first name of the primary contact at the school is

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* 8. The best phone number to reach the school contact person is

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* 9. The email address of the school contact person is

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* 10. Are there written school district policies on management of life-threatening allergies in place?

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* 11. Was district-wide training provided?

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* 12. How often is district-wide training provided?

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* 13. Was school-wide training provided?

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* 14. How often is school-wide training provided?

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* 15. Is there a  written school plan to manage anaphylaxis?

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* 16. Was an epinephrine auto-injector available to the individual experiencing anaphylaxis before emergency personnel arrived?

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* 17. The epinephrine auto-injector used on the individual was

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* 18. How many of the epinephrine auto-injectors were used from a LifeReach Anaphlaxis Emergency Kit?

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* 19. Age of individual who received epinephrine (please check one)

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* 20. Race/ethnicity

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* 21. Date of incident (MM/DD/YYYY)

Date

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* 22. Biological gender of individual who received epinephrine:

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* 23. What brand epinephrine auto-injector was used?

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* 24. What was the dose of the first epinephrine auto-injector given?

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* 25. Was a second epinephrine auto-injector/dose of epinephrine given?

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* 26. What was the dose of the second epinephrine auto-injector given?

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* 27. Did the individual who experienced anaphylaxis have a known life-threatening allergy?

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* 28. Did the individual who experienced anaphylaxis have a known history of asthma?

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* 29. Time of 1st epinephrine administration

Date / Time

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* 30. Was the anaphylaxis trigger known to be one of the following:

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* 31. If food was the trigger, was the food

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* 32. If food, time elapsed between last food exposure and administration of the 1st dose of epinephrine:

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* 33. If insect sting(s), time elapsed between insect sting and administration of the 1st dose of epinephrine:

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* 34. If latex, time elapsed between latex exposure and administration of the 1st dose of epinephrine:

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* 35. If medication administration, time elapsed between medication ingestion and administration of the 1st dose of epinephrine:

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* 36. If exercise, time elapsed between the start of exercise and administration of the 1st dose of epinephrine:

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* 37. Epinephrine was administered by:

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* 38. Individual who administered epinephrine was trained by:

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* 39. Location on campus where epinephrine administered:

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* 40. Lung symptoms experienced (Mark all that apply)

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* 41. Heart symptoms experienced (Mark all that apply)

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* 42. Throat symptoms experienced (Mark all that apply)

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* 43. Skin, nose, eyes symptoms experienced (Mark all that apply)

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* 44. Gastrointestinal symptoms experienced (Mark all that apply)

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* 45. Mental symptoms experienced (Mark all that apply)

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* 46. Other symptoms experienced (Mark all that apply)

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* 47. If a second dose of epinephrine was given, what was the time lapse between the first and second dose?

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* 48. The second dose of epinephrine was administered by

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* 49. Was 9-1-1 called? Or Emergency Medical Services summoned to transport individual to a medical facility?

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* 50. Was the individual who experienced anaphylaxis transported to an emergency department/facility?

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* 51. Individual who experienced anaphylaxis was transported to emergency department by:

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* 52. Onsite outcome:

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