HomeMy WebLinkAbout20161787.tiffo
Memorandum
TO: Steve Moreno, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH
Executive Director
Department of Public Health & Environment
DATE: May 4, 2018
SUBJECT: Renewal of Agreement with Weld County
(Pawnee) School District RE -12 for an
Epinephrine Auto -Injection Program
For the Board's approval is an Agreement Extension/Renewal between the Weld County Board of
County Commissioners on behalf of Dr. Mark E. Wallace, Executive Director of the Weld County
Department of Public Health and Environment (Weld County), and Weld County (Pawnee) School
District RE -12 (District).
Colorado law, through House Bill 13-1171, permits the governing authority of a school to adopt
and implement policies that allow the schools under its jurisdictions to stock a supply of
epinephrine auto -injectors (commonly known as "epi pens") and administer an epi pen in
emergency situations in schools. Pursuant to law, the governing authority must have a standing
order and protocol from a licensed physician, physician assistant, or advanced practice nurse with
prescriptive authority in order to obtain a stock supply of the epinephrine auto -injectors. Due to
limited funding and/or the rural nature of many Weld County school districts, they do not have a
licensed medical professional with prescriptive authority on staff, or even a physician in their
community, who can accommodate this requirement.
In May of 2016, the County entered into an Agreement with the District to allow Dr. Mark E.
Wallace to serve as the Physician of Record for the sole purpose of administrating the epinephrine
auto -injector program in schools under their jurisdiction. The District has requested that Weld
County extend the term of this Agreement as permitted in the original Agreement for an additional
two years beginning April 1, 2018, through March 31, 2020. Furthermore, the original Agreement
permits the District and Weld County, upon mutual consent, to extend this Agreement for one
more additional two-year period following the end of this Agreement's term. This Agreement may
be terminated sooner, without cause, by either party upon 30 days written notice.
This renewal Agreement was approved for placement on the Board's agenda via pass -around dated
May 1, 2018.
I recommend approval for the renewal of this Agreement with Weld County (Pawnee) School
District RE -12 for an Epinephrine Auto -Injection Program.
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CONTRACT AGREEMENT EXTENSION/RENEWAL BETWEEN
THE WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
AND WELD COUNTY SCHOOL DISTRICT RE -12
This Agreement Extension/Renewal ("Renewal"), made and entered into 1st day of April, 2018, by and between the Board
of Weld County Commissioners, on behalf of the Weld County Department of Public Health and Environment, hereinafter referred
to as the "Department", and Weld County School District RE -12, hereinafter referred to as the "Contractor".
WHEREAS the parties entered into an agreement (the "Original Agreement") identified by the Weld County Clerk to the
Board of County Commissioners as document No. 2016-1787approved on June 13, 2016.
WHEREAS the parties hereby agree to extend the term of the Original Agreement in accordance with the terms of the
Original Agreement, which is incorporated by reference herein, as well as the terms provided herein.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows:
• The Original Agreement will end on March 31, 2018.
• The parties agree to extend the Original Agreement for an additional 2 year period, which will begin April 1, 2018, and will
end on March 31, 2020.
• The Renewal, together with the Original Agreement, constitutes the entire understanding between the parties. The
following change is hereby made to the Contract Documents:
1. None
2.
• All other terms and conditions of the Original Agreement remain unchanged.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written.
CONTRACTOR:
Bret Robinson
Printed Name
Signature
ATTES
Weld
BY
Deputy Cler
BOARD OF COUNTY COMMISSIONERS
WELD C • UNTY, COLORADO
eve Moreno, Chair
MAY 072D18
020/6- /717
RESOLUTION
RE: APPROVE INTERGOVERNMENTAL AGREEMENT FOR EPINEPHRINE AUTO -
INJECTION PROGRAM AND AUTHORIZE CHAIR TO SIGN - SCHOOL DISTRICT
RE -12
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with an Intergovernmental Agreement for the
Epinephrine Auto -Injection Program between the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld County, on behalf of the Department of
Public Health and Environment, and School District RE -12, commencing April 1, 2016, and ending
March 31, 2018, with further terms and conditions being as stated in said agreement, and
WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Intergovernmental Agreement for the Epinephrine Auto -Injection
Program between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Public Health and Environment,
and School District RE -12 be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair Pro-Tem be, and hereby is,
authorized to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 13th day of June, A.D., 2016, pro nunc tunc April 1, 2016.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST:djt,/{yU V �C.Lto;ek
Weld County Clerk to the Board
BY:
uty Clerk to the Board
APPR VED AS TO FORM:
County Attorney
Date of signature: 7/(O/ /G,
11/1
EXCUSED
Mike Freeman, Chair
`�- LSean P. Conway, Pro-Tem
rU �� �- <s,�
J
Julie A.Cozad
EXCUSED
Barbara Kirkmeyer
O1,
Moreno
C./ -IL. CST) 2016-1787
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Memorandum
TO: Mike Freeman, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH
Executive Director
Department of Public Health & Environment
DATE: June 6, 2016
SUBJECT: Agreement with Weld County (Pawnee)
School District RE -12 for an Epinephrine
Auto -Injection Program
Enclosed for the Board's approval is an Agreement between the Weld County Board of County
Commissioners on behalf of Dr. Mark E. Wallace, Executive Director of the Weld County
Department of Public Health and Environment, and Weld County (Pawnee) School District RE -12.
Colorado law, through House Bill 13-1171, permits the governing authority of a school to adopt
and implement policies that allow the schools under its jurisdictions to stock a supply of
epinephrine auto -injectors (commonly known as "epi pens") and administer an epi pen in
emergency situations in schools. Pursuant to law, the governing authority must have a standing
order and protocol from a licensed physician, physician assistant, or advanced practice nurse with
prescriptive authority in order to obtain a stock supply of the epinephrine auto -injectors. Due to
limited funding and/or the rural nature of many Weld County school districts, they do not have
a licensed medical professional with prescriptive authority on staff, or even a physician in their
community, who can accommodate this requirement.
Weld County School District RE -12 has requested that Dr. Mark E. Wallace serve as the Physician
of Record for the sole purpose of administrating the epinephrine auto -injector program in
schools under their jurisdiction. The term of this agreement will be for two years beginning April
1, 2016, through March 31, 2018, and the Weld County Board of County Commissioners may
extend this agreement for up to two additional two year periods. This agreement may be
terminated sooner, without cause, by either party upon 30 days written notice.
This continuation contract was approved for placement on the Board's agenda via pass -around
dated May 25, 2016. I recommend approval of this agreement with Weld County School District
RE -12 for an Epinephrine Auto -Injection Program.
2016-1787
INTERGOVERNMENTAL AGREEMENT BETWEEN THE DIRECTOR OF
THE WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND
ENVIRONMENT AND WELD COUNTY SCHOOL DISTRICT RE -12 FOR AN
EPINEPHRINE AUTO -INJECTION PROGRAM
THE AGREEMENT is made by and between the Board of County Commissioners of
Weld County by and on behalf of Dr. Mark Wallace, Executive Director of the Weld
County Department of Public Health and Environment (hereinafter referred to as
Director), and Weld County School District RE -12 (hereinafter referred to as School
District). The School District and the Weld County Commissioners on behalf of Dr.
Wallace may be referred to collectively in this agreement as "the parties".
WHEREAS, House Bill Number 13-1171 concerning the use of epinephrine auto -
injectors in emergency situations in a school setting was passed by the Colorado General
Assembly, approved by the Governor, and became effective on May 28, 2013;
WHEREAS, Colorado law now allows the governing authority of a school to adopt and
implement policies whereby schools under its jurisdiction may acquire and maintain a
stock supply of epinephrine auto -injectors and authorize the school nurse or other
designated personnel to administer an epinephrine auto -injector to any student that the
designated person believes is experiencing anaphylaxis, regardless of whether the student
has a prescription for an epinephrine auto -injector;
WHEREAS, in order to obtain a stock supply of epinephrine auto -injectors the governing
authority of a school must have a standing order and protocol from a licensed physician,
physician assistant, or advanced practice nurse with prescriptive authority and certain
Weld County school districts do not have a licensed person on staff;
WHEREAS, in such situations Dr. Mark Wallace, Director of the Weld County
Department of Public Health and Environment, will act as the Physician of Record, so
that these school districts without a medical professional with prescriptive authority may
participate in the epinephrine auto -injector program;
WHEREAS, pursuant to Title 29, Article I, Part 2, C.R.S., the Parties are authorized to
contract with one another to provide any function, service or facility lawfully authorized
to each.
NOW, THEREFORE, FOR AND INCONSIDERATION of covenants and agreements
below appearing, the parties agree as follows:
I.
RESPONSIBILITIES OF THE DIRECTOR
The Director will act as the Physician of Record for the School District for the sole
purpose of administrating the epinephrine auto -injection program. As the Physician of
Record for the School District the Director shall perform the following functions:
1
ow/10'/70 7 I/
1. Sign the "Standing Order Certification Form" that allows the School
District to purchase and have delivered directly to a school for use by a
designated person, in a situation determined to be an anaphylaxis reaction,
a stock supply of epinephrine auto -injectors;
2. Sign the "Standing Orders and Protocol" that sets forth the administration,
follow up, and storage protocols to be used when administering an
epinephrine auto -injector;
3. Review and, if proper, approve a training provider and curriculum that is
consistent with section 25-47-104, C.R.S. (Colorado Revised Statues) and
will be used by the School District in training appropriate and necessary
staff;
4. Review and, if proper, approve the policy that the School District will
implement with regards to administration of an epinephrine auto -injection
program.
II.
RESPONSIBILITIES OF SCHOOL DISTRICT
The School District shall do the following:
1. Adopt and implement a policy whereby schools under its jurisdiction
may acquire and maintain a stock supply of epinephrine auto -injectors;
2. Adopt a policy whereby schools under its jurisdiction may authorize a
nurse or other designated school personnel to administer an epinephrine
auto -injector to a student if determined to be necessary and appropriate;
3. In accordance with section 25-47-104, C.R.S., and this agreement,
provide approved training to any nurse or designated person at the
school who will be authorized to administer an epinephrine auto -
injector;
4. In accordance with training that is received, store the epinephrine auto -
injectors at appropriate temperatures, in areas that cannot be access by
non -authorized personnel, and dispose of any used auto -injector
properly;
5. Comply with any and all applicable state statutes, rules, and regulations
in implementing an epinephrine auto -injector program.
21
III.
GENERAL TERMS AND CONDITIONS
A. Liability Coverage.
1. General Liability. The parties shall exchange evidence of
general liability insurance coverage. The coverage must at least be in
the minimum amount required by the Colorado Governmental
Immunity Act for protection from claims for bodily injury, death,
property damage, or personal injury which may arise through the
execution of this contract. Such evidence shall be approved by each
recipient prior to the commencement of this agreement.
2. Professional Malpractice. The Director certifies that he carries
professional medical malpractice insurance. The Director will provide
documentation of this policy upon request by the School District.
3. Good Samaritan Protections. Pursuant to section 25-47-107,
C.R.S., authorized individuals covered under this agreement are
immune to criminal and civil liability with regards to the
administration of an epinephrine injector program unless the actions
taken by an authorized individual can be shown as grossly negligent or
willful and wanton.
4. Immunity. This agreement does not limit or reduce any other
immunity or defense that may be available to either party pursuant to
state law.
B. Termination.
1. For Cause: If the Director determines that a situation related to
the epinephrine auto -injection program at the School District or at one
or more of the schools under the governing authority of the School
District, violates any laws, policies or procedures that he has approved,
is endangering a student, or otherwise puts his medical license at risk,
he may immediately withdrawal his approval as the Physician of
Record from the Standing Order and Protocol and for use in obtaining
a stock supply of epinephrine auto -injectors for the School District.
2. Convenience: This agreement may be terminated without cause by
either party upon 30 days written notice. Notice shall be given in
writing to the Director or the School District Superintendent as
appropriate. Timing of termination may be extended by the Director, if
needed for the School District to obtain a new Physician of Record.
C. Entire Agreement. This Intergovernmental Agreement contains the entire
understanding of the parties with respect to the subject matter hereof, and all other
understandings or agreements shall be deemed merged into this Agreement. Amendments
of this Intergovernmental Agreement may only be made if in writing and signed by both
of the parties hereto.
D. Third Party Beneficiaries. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties and
nothing in this Agreement shall give or allow any claim or right of action whatsoever by
any other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties receiving services
or benefits under this Agreement shall be an incidental beneficiary only. Nothing in this
Intergovernmental Agreement shall be deemed as a waiver of immunity or liability limits
granted to the Director and the School District under the Colorado Governmental
Immunity Act.
E. Notices. Any notice provided for in this Agreement shall be in writing and
shall be served by personal delivery or by certified mail, return receipt requested, postage
prepaid, at the addresses set forth below, until such time as written notice of a change is
received from a party wishing to make a change of address. Any notice mailed and/or
served as set forth above, shall be deemed delivered and effective upon receipt or
delivery.
WELD COUNTY SCHOOL
DISTRICT RE -12:
Bret Robinson
Superintendent of Schools
brobinsongpawneeschool.org
25 Chatoga Avenue
Grover, CO 80729
Tani McDaniel, RN
Grover School Nurse
tmcdaniel@cboces.org
25 Chatoga Avenue
Grover, CO 80729
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH & ENVIRONMENT:
Mark E. Wallace, MD, MPH
Executive Director
mwallace(a)co.weld.co.us
1555 North 17`x' Avenue
Greeley, CO 80631
Tanya Geiser
Administrative Services Director
tkeiser+alco.weld.co.us
1555 North 17'i' Avenue
Greeley, CO 80631
(970) 304-6410
Bret Robinson
Superintendent of Schools
IV.
TERM OF CONTRACT
The term of this agreement shall be for two years, beginning on the 1st day of April,
2016, and shall continue through the 31st day of March, 2018. The Weld County Board
of County Commissioners, on behalf of the Director may, at its sole discretion, extend the
contract for up to two (2) additional two year periods.
PRESERVATION OF IMMUNITY. Nothing in the Agreement shall be construed (i)
as a waiver by either party of immunity provided by common law or by statute,
specifically including the Colorado Governmental Immunity Act, Section 24-10-101.
et.seq. C.R.S., as it may be amended from time to time; (ii) as creating as assumption of
any duty or obligation with respect to any third party where no such duty previously
existed; or (iii) as creating any rights enforceable by such third parties.
EXCUTED THISVI DAY OF /d s' R -t 1-- , 2016.
WELD COUNTY SCHOOL DISTRICT RE -12:
Date if/
WELD COUNTY:
I(� L
ATTEST: CIC � th G ; 1�
Weld County erk to a Board
BY:
5IPage
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
i,17c
Sean P. Conway, Pro-Te 1 3 2016
APPROVED AS TO SUBSTANCE:
Mark E. Wallace, Executive Director
O1,46/4, -17116)
File: JLCD
Stock Epinephrine School Policy
Administering Medications to Students
School personnel shall not administer prescription or nonprescription medications to
students unless appropriate administration cannot reasonably be accomplished
outside of school hours and the student's parent/guardian is not available to
administer the medication during the school day.
Medication may be administered to students by school personnel whom a registered
nurse has trained and delegated the task of administering such medication. For
purposes of this policy, the term "medication" includes both prescription medication
and nonprescription medication. The term "nonprescription medication" includes but
is not limited to over-the-counter medications, homeopathic and herbal medications,
vitamins and nutritional supplements. Medication may be administered to students
by the school nurse or other school designee only when the following requirements
are met:
1. Medication shall be in the original properly labeled container. If it is a
prescription medication, the student's name, name of the medication, dosage,
how often it is to be administered, and name of the prescribing health care
practitioner shall be printed on the container.
2. The school shall have received written permission to administer the medication
from the student's health care practitioner with prescriptive authority under
Colorado law.
3. The school shall have received written permission from the student's
parent/guardian to administer the medication to the student.
4. The parent/guardian shall be responsible for providing all medication to be
administered to the student.
1
Pawnee School District 12
File: JLCD
NOTE 1: State law permits local boards of education to adopt a policy authorizing a student to
possess and self-administer any medication prescribed by a licensed health care practitioner
on school grounds, upon a school bus, or at any school -sponsored event. C.R.S. 22-1-119.3; 1
CCR 301-68, Rule 6.00. However, such policy must prohibit students from possessing or self-
administering medical marijuana on school grounds or at any school -sponsored event. C.R.S.
22-1-119.3 (3)(c). A board that chooses to adopt such a policy is then exempt from the
requirements of the Colorado Schoolchildren's Asthma, Food Allergy, and Anaphylaxis Health
Management Act (the "Act"). C.R.S. 22-1-119.3 (5).
This policy does not permit students to self -carry any prescription medication and
instead reflects the Act's requirements for self -administration of medication for asthma,
allergy or anaphylaxis only. Districts should consult with their own legal counsel if they wish
to permit students to self -carry and self-administer any prescription medication.
Self -administration of medication for asthma, allergies or anaphylaxis
A student with asthma, a food allergy, other severe allergies, or a related, life -
threatening condition may possess and self-administer medication to treat the
student's asthma, food or other allergy, anaphylaxis or related, life -threatening
condition. Self -administration of such medication may occur during school hours, at
school -sponsored activities, or while in transit to and from school or a school -sponsored
activity. Student possession and self -administration of such medication
shall be in accordance with the regulation accompanying this policy.
Authorization for a student to possess and self-administer medication to treat the
student's asthma, food or other allergy, anaphylaxis or other related, life -threatening
condition may be limited or revoked by the school principal after consultation with the
school nurse and the student's parent/guardian if the student demonstrates an
inability to responsibly possess and self-administer such medication.
Use of stock epinephrine auto -injectors in emergency situations
The district shall have a stock supply of epinephrine auto -injectors for use in
emergency anaphylaxis events that occur on school grounds. Any
administration of a stock epinephrine auto -injector to a student by a district
employee shall be in accordance with applicable state law, including
applicable State Board of Education rules.
The district's stock supply of epinephrine auto -injectors is not intended to
replace student -specific orders or medication provided by the student's
parent/guardian to treat the student's asthma, food or other allergy,
anaphylaxis or related, life -threatening condition.]
Student possession, use, distribution, sale or being under the influence of
medication inconsistent with this policy shall be considered a violation of Board
policy concerning drug and alcohol involvement by students and may subject the
student to disciplinary consequences, including suspension and/or expulsion, in
accordance with applicable Board policy.
2
Pawnee School District 12
File: JLCD
LEGAL REFS.: C.R.S. 12-38-132 (delegation of nursing tasks)
C.R.S. 22-1-119 (no liability for adverse drug reactions/side effects)
C.R.S. 22-1-119.5 (Colorado Schoolchildren's Asthma, Food Allergy, and
Anaphylaxis Health Management Act)
C.R.S. 22-2-135 (Colorado School Children's Food Allergy and Anaphylaxis
Management Act)
C.R.S. 24-10-101 et seq. (Colorado Governmental Immunity Act)
1 CCR 301-68 (State Board of Education rules regarding student possession
and administration of asthma, allergy and anaphylaxis management medications
or other prescription medications)
6 CCR 1010-6, Rule 9-105 (regulations)
CROSS REFS.: JICH, Drug and Alcohol Involvement by Students
JKD/JKE, Suspension/Expulsion of Students
JLCDA*, Students with Food Allergies
JLCE, First Aid and Emergency Medical Care
NOTE 2: The Colorado Department of Education (CDE), in collaboration with various school districts
and other organizations, has created numerous guidelines regarding medication administration in the
school setting. These guidelines are available on CDE's website.
3
Pawnee School District 12
STANDING ORDERS and PROTOCOL
Epinephrine Auto -Injector Administration for Anaphylaxis
In the event of an anaphylactic reaction in any individual in the school setting, epinephrine will be administered
by the school nurse or designated school personnel. This Standing Order is for the use of an epinephrine auto -
injector in such situations for any student with a known or unknown allergic reaction.
In the case of students with a history of anaphylaxis or other severe allergic reactions, epinephrine will be
administered according to specific individualized prescriptive orders documented in their individualized
healthcare plan using the student's own epinephrine. If no such orders exist or the epinephrine is not readily
available, the Standing Orders given in this document will be used.
DEFINITION: Anaphylaxis is a severe allergic reaction which can be life threatening and occur within minutes
after a triggering event or up to hours later.
CAUSES: Extreme sensitivity to one or more of the following:
Food Medication Latex Insect Stings Idiopathic (unknown)
SUBJECTIVE AND PHYSICAL FINDINGS: One or more of the following:
LUNG: Short of breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy, confused
THROAT: Tight, hoarse, trouble breathing or talking/swallowing
MOUTH: Obstructive swelling (tongue and/or lips)
SKIN: Extensive hives over body
Or combination of symptoms from different body areas:
SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips)
GUT: Vomiting, cramping abdominal pain
STANDING ORDER:
1. Based on symptoms, determine that an anaphylactic reaction appears to be occurring or if allergen has
been ingested. Act quickly. If is safer to give epinephrine than to delay treatment. Anaphylaxis is a life -
threatening reaction.
2. The school nurse or any individual trained and designated has permission to administer or assist any
student to administer their prescribed emergency epinephrine auto -injector as needed, and according
to their medication order and emergency healthcare plan.
3. The school nurse or designated personnel who have been specially trained and designated to recognize
anaphylaxis has permission to administer epinephrine using a stock epinephrine auto -injector if they
believe a student is experiencing a life -threatening allergic reaction.
4. Select appropriate epinephrine auto -injector to administer, based on weight of child.
Dosage: 0.15 mg Epinephrine auto -injector IM, if less than 66 pounds (* PK through 3rd)
0.30 mg Epinephrine auto -injector, if 66 pounds or greater (* 4th through 12th)
* General guidelines but if unsure of weight, use higher dose.
Frequency: If symptoms continue or increase, a second dose should be administered 5 to 15 minutes
after first dose
5. Inject epinephrine via auto -injector: Pull off safety release cap. Depending on the device, press firmly
into upper, outer thigh. (through clothes if necessary) Hold in place according to instructions for
individual device to deliver medication and then remove. Massage the area for 10 more seconds.
Document the time the medication was administered and your signature in the medication log.
6. Have another staff member call 911 immediately to activate the Emergency Medical System (EMS).
Advise 911 operator that anaphylaxis is suspected and epinephrine has been given. Ask that EMS bring
additional doses of epinephrine.
7. Keep the individual either lying down or slightly propped up, whichever is most comfortable. If they lose
consciousness, check if they are breathing and have a pulse. If not, begin CPR (cardiopulmonary
resuscitation) and continue CPR until the individual regains a pulse and is breathing or until EMS arrives
and takes over.
8. Call parents/guardian and School Nurse to advise of situation
9. Repeat the dose after 5 to 15 minutes if symptoms persist or increase.
10. Stay with the student until EMS arrives, continuing to follow the directions in number 7 above.
11. Provide EMS with the used Epinephrine auto -injector labeled with name, date, and time administered to
transport to the ER with the student.
FOLLOW UP (to be done the same day as the event)
1. Complete required district documentation of incident including State Epinephrine/Anaphylaxis
Report. http://fs24.formsite.com/305medicaid/form5/index.html
2. Order replacement epinephrine auto-injector(s).
STORAGE: The Epinephrine Auto -injectors should be stored in a secured and central location that is accessible to
school staff.
Licensed Prescriber Signature: 4'c"-"e'Ll7Alre
R�
Print Name:
fir- vlc �k \piO aCe
* Effective for School Year:
*Must be renewed annually and with any change in prescriber.
—I.
Date: Co
STANDING ORDER CERTIFICATION FORM:
Practitioner Name:
Dr. M ARK WALL A -CE
Practitioner Address:
M55 1\1or-4h 1``i1+' Aiel.)u€, €eelc C' O 8 31
Practitioner Phone: '
I -]o ) LI - ELI ao
Date:
Shipment Information
Recipient Name:
—1-PkaCZA MC6RtstF.t
Recipient Title:
-R— 615- R Eb T W S E -
Recipient Address:
25 C h o Pkq exn xe, C-- r-OVe r Cc
By signing this Certification form, I certify that, under applicable state law, I may (1) purchase and
possess quantities of EpiPen® (epinephrine) or EpiPen Jr® Auto -Injectors (the "Product'), (2) prescribe,
furnish and administer the Product to patients, (3) issue standing orders or otherwise delegate to
appropriate persons the authority to prescribe, furnish or administer the Product to a student at a School
or involved in a School -related activity, and (4) ship, or direct shipment of, quantities of the Product to a
School for prescribing, furnishing or administering to a student at the School or involved in a School -
related activity.
Practitioner Signature: Date. �--Z'�- l4:1
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