Severe Allergic Reaction and/or Epinephrine Administration Report

CDE School Health Services Office | 2024-2025

1 CCR 301-68 6.00 Reporting Requirements 6.01: Schools must submit a report to the State School Nurse Consultant at the Department of Education within 10 days regarding any incident at the school or a school-related event involving a severe allergic reaction, the administration of an epinephrine auto-injector, or both.

Access printable worksheet (optional) to collect answers before submitting on this form.

CDE Accessibility Statement

Name of School District/ or Charter/ or BOCES: *

Name of School: *

Date and time of occurrence *

Age of person who experienced
severe allergic reaction: *

The person who experienced
severe allergic reaction was a: *

Does the person have
a known allergy? *

Was an allergy
action plan available? *

Diagnosis or history of asthma: *

If known, specify trigger
that precipitated severe
allergic reaction: *

If response was OTHER, please explain:

If food was a trigger, please
specify which food: *

If response was OTHER, please explain:

Location where symptoms
developed: *

If response was OTHER, please explain:

How was the incident
triggered? *

If response was OTHER, please explain:

Respiratory Symptoms
(check all that apply):

	Respiratory
Cough	Respiratory
Difficulty breathing	Respiratory
Hoarse voice	Respiratory
Nasal congestion/runny nose	Respiratory
Swollen throat/and or tongue	Respiratory
Shortness of breath	Respiratory
Itching - mouth/throat	Respiratory
Tightness - chest/throat	Respiratory
Wheezing	Respiratory
Does not apply	Respiratory

GI Symptoms
(check all that apply):

	GI
Abdominal discomfort	GI
Diarrhea	GI
Difficulty swallowing	GI
Nausea	GI
Vomiting	GI
Does not apply	GI

Skin Symptoms
(check all that apply):

	Skin
Flushing	Skin
General itching	Skin
General rash	Skin
Hives	Skin
Lip Swelling	Skin
Localized rash	Skin
Pale	Skin
Does not apply	Skin

Cardiovascular Symptoms
(check all that apply):

	Cardiovascular
Chest discomfort	Cardiovascular
Bluish skin	Cardiovascular
Dizziness	Cardiovascular
Weak pulse	Cardiovascular
Headache	Cardiovascular
Heart racing	Cardiovascular
Does not apply	Cardiovascular

Other Symptoms
(check all that apply):

	Other
Sweating	Other
Irritability	Other
Loss of consciousness	Other
Metallic taste	Other
Red eyes	Other
Sneezing	Other
Does not apply	Other

Does your school have stock
epinephrine? *

Auto-injector used: *

Epinephrine administered by: *

If response was OTHER, please explain:

Location where epinephrine was
administered: *

If response was OTHER, please explain:

Location of epinephrine
storage: *

If response was OTHER, please explain:

Disposition:

Transferred to ER? *

If transferred, how? *

If response was OTHER,
please explain:

Was a second epi-pen
dose required? *

If response was yes,
was that dose
administered at the school
prior to arrival of EMS?

Time elapsed between
communication of
symptoms and
administration of
epinephrine

	Hours	Minutes
Time	Hours	Minutes

Form Completed By:

First Name *

Last Name *

Title: *

Phone Number: *

Date Form
Completed: *

Email address: *

Using your mouse, please place your signature in the box below: *

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