Epinephrine/Anaphylaxis Reports

CDE Health and Wellness - Report of Anaphylaxis and/or Epinephrine Administration (2022-2023)

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.

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

Name of School: *

Date and time of occurrence *

Age of person who experienced severe allergy: *

Does the person have
a known allergy? *

Was an allergy
action plan available? *

Diagnosis or History of Asthma: *

If known, specify trigger that
precipitated this allergic episode: *

If response was OTHER
from drop down menu
on the left, please explain.

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

Location where symptoms developed: *

If response was OTHER
from drop down menu to the left,
please explain:

How was the incident triggered?
Please choose one from the following
drop down menu: *

If response was OTHER
from drop down menu to the left,
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
(choose one) *

Epinephrine administered by
(please choose one): *

If response was OTHER
from drop down menu on the left,
please give a short answer regarding details (if this
does not apply, please type N/A):

Location where epinephrine was
administered (please choose one): *

If response was OTHER
from drop down menu on the left,
please give a short answer regarding details

Location of epinephrine storage
(please choose one): *

If response was OTHER
from drop down menu on the left,
please give a short answer regarding details

Disposition:

Transferred to ER?
(Please choose one) *

If transferred,
how? (choose one) *

If response was OTHER
from drop down menu
on the above, please give
a short answer regarding details

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: *

clear

Colorado Department of Education Educational Data Advisory Committe approval stamp