Epinephrine/Anaphylaxis Reports

CDE Health and Wellness - Report of Anaphylaxis and/or Epinephrine Administration (2021-22)

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 *

Student Age: *

Does student 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: *

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Colorado Department of Education Educational Data Advisory Committe approval stamp