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
Respiratory Symptoms
(check all that apply):
 Respiratory
Cough
Difficulty breathing
Hoarse voice
Nasal congestion/runny nose
Swollen throat/and or tongue
Shortness of breath
Itching - mouth/throat
Tightness - chest/throat
Wheezing
Does not apply
GI Symptoms
(check all that apply):
 GI
Abdominal discomfort
Diarrhea
Difficulty swallowing
Nausea
Vomiting
Does not apply
Skin Symptoms
(check all that apply):
 Skin
Flushing
General itching
General rash
Hives
Lip Swelling
Localized rash
Pale
Does not apply
Cardiovascular Symptoms
(check all that apply):
 Cardiovascular
Chest discomfort
Bluish skin
Dizziness
Weak pulse
Headache
Heart racing
Does not apply
Other Symptoms
(check all that apply):
 Other
Sweating
Irritability
Loss of consciousness
Metallic taste
Red eyes
Sneezing
Does not apply

Disposition:

Time elapsed between
communication of
symptoms and
administration of
epinephrine *
 HoursMinutes
Time

Form Completed By:

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