Medical Management Plan for Student with Allergies

ST. JOHNS COUNTY SCHOOL DISTRICT
Rev. 07/2025

Florida Statute 1002.20
Florida law states a student with life-threatening allergies may carry an epinephrine auto injector while at school and school-sponsored activities with approval from his or her parents and physician. The above named child may carry and self-administer his or her epinephrine auto injector.

Medical Management Plan

School Year:

ALLERGY

Student Name	Date of Birth	Physician’s Name	Phone #	Address	Fax #

Allergy To: Asthma: Yes / No

*Higher risk for severe reaction if student has asthma*

Step 1: Treatment

Symptoms: Give Checked Medication
*To be determined by physician authorizing treatment*

• If a food allergen has been ingested, but no symptoms:
  • Epinephrine
  • Antihistamine
• MOUTH: itching, tingling, or swelling of lips, tongue, mouth:
  • Epinephrine
  • Antihistamine
• SKIN: Hives, itchy rash, swelling of the face or extremities:
  • Epinephrine
  • Antihistamine
• GUT: nausea, abdominal cramps, vomiting, diarrhea:
  • Epinephrine
  • Antihistamine
• THROAT*: tightening of throat, hoarseness, hacking cough:
  • Epinephrine
  • Antihistamine
• LUNG: shortness of breath, repetitive coughing, wheezing:
  • Epinephrine
  • Antihistamine
• HEART: thready pulse, low blood pressure, fainting, pale, blueness:
  • Epinephrine
  • Antihistamine
• Other:
  • Epinephrine
  • Antihistamine

If reaction is progressing (several of the above areas affected), give:

• Epinephrine
• Antihistamine

*Potentially life-threatening. The severity of symptoms can quickly change*

Epinephrine Dosage

Route: IM or Nasal (circle one)
EpiPen®: 0.15 mg OR 0.30 mg
Auvi-Q: 0.15 mg OR 0.30 mg
Generic Epinephrine Auto Injector: 0.15 mg OR 0.30 mg

Antihistamine/Other: Medication/dose/route

Step 2: Emergency Calls

• Call 911. State that an allergic reaction has been treated, and additional epinephrine may be needed.
• Call parent/guardian or emergency contact if unable to reach parent.

Nursing services are recommended for the care of this student during the school day.

Physician’s Signature: ___________________ Date: _______________

Parent/Guardian Signature: ___________________ (Required)

Date: _______________

Physician’s Signature: ___________________ (Required)

Date: _______________

Continued Allergy Plan for (Student NAME)

IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine during anaphylaxis.

• Is your child compliant with their current treatment regime? Yes / No
• Does your child function independently with medication administration? Yes / No
• Are there any activity restrictions for your child? Yes / No
• If yes, please list: ___________________________________________________________

Parent/Guardian Authorization

I authorize my child’s school nurse to assess my child as it relates to his or her special health care needs and to discuss these needs with my child’s physician as needed throughout the school year. I understand this is for the purpose of generating a health care plan for my child. I understand I may withdraw this authorization at any time and that this authorization must be renewed annually.

As the parent or guardian of the student named above, I request that the principal or principal’s designee assist in the administration of medication/treatment prescribed for my child. I understand that under provisions of Florida Statute 1006.062, there shall be no liability for civil damages as a result of the administration of medication when the person administering such medication acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances. I also grant permission for school personnel to contact the physician listed above if there are any questions or concerns about the medication. I have read the guidelines and agree to abide by them. I authorize the physician to release information about this condition to school personnel.

Parent/Guardian Signature: ___________________ Print Name: ___________________ Date: _______________

Parent/Guardian Contact Information

Parent/Guardian: ___________________________________ Cell: ____________________________________

Work: ___________________________________

Parent/Guardian: ___________________________________ Cell: _____________________________________

Work: ___________________________________