anaphylaxis information - Dufferin-Peel Catholic District School Board
Contents
1. SECTION 1 THE PARENT S GUARDIAN S REQUEST AND CONSENT FOR THE ADMINISTRATION OR AN INJECTION OF MEDICATION IN AN EMERGENCY IN THE SCHOOL Home Telephone Home Telephone Business Telephone Business Telephone I We request that the Dufferin Peel Catholic District School Board provide for the administration of an emergency injection of medication for my our son daughter in the event that the following should happen I We understand that a a Medical Doctor must consent to this request in accordance with Section 2 of this form b only a limited supply of the medication may be kept at the school as prescribed by the Doctor c the medication must be brought to the school in a closed container and the label must detail the name of the student the type name of the medication and the size of the dosage d if the medication is not provided to the school contact will be made with the parent s guardian s and will also be made with parent s guardian s under any other exceptional circumstances e g pupil refuses medication I We consent to a the establishment of a service for the administration of medication in an emergency situation discussing any aspect of the service with a public health nurse where the need arises Signature of Parent Guardian Date PLEASE HAVE FAMILY DOCTOR COMPLETE PART 2 ON REVERSE SIDE OF THIS FORM 514 02 514 02 GF400 C cont d REQUEST AND CONSEN2. Should you have any questions regarding the administration of medication or the emergency treatment of life threatening allergies by school staff please make an appointment to see the Principal during the last week in August prior to your child beginning school Yours sincerely Principal Attach 514 02 514 02 GF400 B APPENDIX B Board Letterhead REQUEST AND CONSENT FOR THE ADMINISTRATION OF EPINEPHRINE EPI PEN TO BE COMPLETED BY THE PARENT S GUARDIAN S SECTION A Student Name Date of Birth Surname First Year Month Day Gender Student Number Male Female Home Telephone Number Medic Alert D Yes No Teacher Classroom Number Fathers Name Home Telephone Number Business Number Mother s Name Home Telephone Number Business Number Legal Guardian Home Telephone Number Business Number Emergency Contact Person Telephone Number EXPIRY DATE OF EPI PEN We understand that a The goal of the board s anaphylaxis policy is to provide a safe environment for our child with a life threatening allergy but it is not possible for the school to reduce the risk to zero b Teachers and Principals and other school staff are not health professionals and have no more information about the medical condition of my our child than that which has been provided to them They are not experts in recognizing the symptoms of my our
3. child s medical condition or in treating it c Our child s medication needs to be updated prior to its expiry date I We as parent s guardian s are responsible for ensuring that the Epi Pen e is contained in the original container e is clearly labelled with the name of the child e has clearly indicated name of physician The following Emergency Plan A C T is from Anaphylaxis Canada Administer the Epi Pen immediately when the child displays any of the anaphylactic symptoms Call 911 Transport the child by ambulance to hospital even if symptoms subside I We have reviewed the Responsibilities of Parents Guardians of an Anaphylactic Pupil and have discussed the Responsibilities of the Anaphylactic Student with our child Check appropriate box YES NO Continued on Back Page 11 514 02 514 02 GF400 B cont d REQUEST AND CONSENT FOR THE ADMINISTRATION OF EPINEPHRINE EPI PEN Continued TO BE COMPLETED BY THE PARENT S GUARDIAN S SECTION B I We give consent that the Anaphylaxis Emergency Treatment Form with the picture of my our child can be posted in appropriate locations of the school e g health room staff room pupils classroom It is understood that the reason for this display is to enable Board personnel to be better able to respond to potential emergencies In the event of our child experiencing an anaphylactic medical emergency I We
4. AXIS CANADA BROCHURE DO YOU OR A LOVED ONE HAVE A LIFE THREATENING ALLERGY Phone Numbers 1 866 785 5660 416 785 5666 Fax 416 785 0458 E mail info anaphylaxis ca Web www anaphylaxis ca 4 ALLERGY ASTHMA INFORMATION ASSOCIATION AATA PRODUCT BOOKLET SEPT 06 1 888 250 2298 www aaia ca SPECIFICS TAKING CONTROL FOOD ALLERGIES amp YOU VIDEO DVD VOL 1 TAKING CONTROL WATCHING THE SIGNS VIDEO DVD VOL 3 5 EPI PEN TRAINER amp INSTRUCTIONS FROM ANAPHYLAXIS CANADA amp REGIONAL HEALTH DEPARTMENT ALSO TWINJECT amp YOU DVD amp TRAINER Phone 1 877 TWINJECT Web www twinject ca 6 ANAPHYLAXIS IN SCHOOLS amp OTHER SETTINGS 2005 MANUAL FROM THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY AVAILABLE FROM AAI IA SEE 4 ABOVE 7 POSTER HOW TO USE THE EPI PEN POSTER FROM AATA 8 STOP SIGN FOR INDIVIDUAL CLASSROOMS ELECTRONIC COPY FROM DP H amp S APPENDIX L 9 GAP FORMS GF 400 A Red Folder GF400B GF400C GF400D 39 GAP 514 02 Page 8 Additional Guidelines for Secondary School Pupils Secondary school pupils may possess the necessary level of maturity and responsibility to monitor their environment for allergens and to administer their own prescribed medications both on a regular basis and in the event of an anaphylactic reaction However increased rather than decreased vigilance is needed in secondary school s
5. Dufferin Peel 6 Catholic District E School Board GAP GENERAL ADMINISTRATIVE PROCEDURES SECTION 500 SCHOOL ORGANIZATION AND MANAGEMENT GAP NUMBER 514 02 SUBJECT Medical Procedures Protocol Anaphylactic Reactions Epi Pen Use REFERENCE Board Policy 1 25 EFFECTIVE January 1 2006 REVISED AMENDED October 2008 May 2011 October 2012 REPLACES 514 02 PAGE 1 of 39 CONTENTS Overview Causes Food Allergies Fundraising Activities Create a Safe Environment Know the Signs and Symptons Think F A S T Treatment PROCEDURES 3A s Awareness Avoidance Action A Awareness Identification of Anaphylactic Pupils Identification to All Staff In Service Sharing Information with Other Pupils Sharing Information with Parents Guardians and Parent Groups B Avoidance Providing Allergen Aware Areas Where Possible Lunchroom Eating Area Procedures Hidden Allergens In Service Holidays Celebrations Excursions Supply Teachers Volunteers Others Bus Safety Insect Stings Precautions Additional Guidelines for Secondary School Pupils C Action Emergency Response Plan Individual Student Plan Location of Epi Pens GAP 514 02 Page 2 Overview The Dufferin Peel Catholic District School Board recognizes that some pupils within the school system are susceptible to severe anaphylactic reaction to a particular food drug or insect sting Anaphylactic reactions can be life t
6. F INCIDENT TION DE L INCIDENT HOW WHERE INCIDENT OCCURRED O ET COMMENT L INCIDENT EST SURVENU WITNESSES TEMOINS INDICATE ADULT A OR MINOR M _ INDIQUER ADULTE A OU MINEUR M SCHOOL DETAILS DETAILS DE L ECOLE Address of School Adresse de l cole Person in charge Personne responsable COMPLETED BY REMPLI PAR TELEPHONE 17 514 02 514 02 APPENDIX F School Guide Anaphylaxis Protocol Anaphylaxis is life threatening and can appear suddenly without warning Working as a team of parents and school staff anaphylaxis can be a manageable condition The pupil with an anaphylactic allergy needs the support of the entire school community to stay safe and to prevent an anaphylactic reaction Here are some suggestions to make the school safer for pupils with anaphylaxis If student has no EpiPen Only food provided by care giver Semi annual in service about anaphylaxis and practice with an EpiPen trainer Establish classroom rules No Sharing Food Discourage allergic foods in the classroom Send a letter to the entire school community that the allergic food not be sent to the school as a snack or as a lunch Inform the student s parents well in advance of special events involving food Establish a procedure for informing substitute teachers and support staff Listen to and believe the student He or she may be having a reaction before y
7. R BEST PRACTICES When setting up a school to be allergen aware these are some best practices Identify pupils with allergen upon registration new diagnosis Send home appropriate forms Create a questionnaire asking pertinent questions regarding allergy Have a meeting with all parent s guardian s of children with an anaphylactic allergy and review strategies that reduce risk for student In service all staff about protocol use of EpiPen and your school emergency procedures Exchange information about school procedures and what parental expectations are for student Put up Allergy alert signs at all entrances vending machines as well as doors of classrooms of the pupils with an anaphylactic allergy Send home letters to the whole school population notifying parents that specific allergens are discouraged from entering the school Follow up with a letter or a telephone fall to the parent s guardian s of a child that has brought an allergen into the school This should be performed by the teacher or the principal If a child brings an allergen in their lunch or snack you should have that child eat in an area that is not normally used by the general student population An office or a conference room has been the general practice for most schools Medication should be stored in a location that is easily accessible and NEVER LOCKED Inform organizations accessing permits at school regarding anaphylactic pol
8. RAPHIER OU CRIRE EN LETTRES MOUL ES ONTARIO SCHOOL BOARDS INSURANCE EXCHANGE FONDS D CHANGE D ASSURANCE DES CONSEILS SCOLAIRES DE L ONTARIO INCIDENT REPORT FORM RAPPORT D INCIDENT To be completed by Person In Charge Not to be completed by Parent or Injured Party remplir par la personne responsable remplir par une personne autre que le parent ou la personne bless e 1 INJURED PERSON S PE NNE S BLESSE Last Nom de tamille First Prenom Street Rus City Ville lt DETAILS OF INCIDENT DETAILS DE L INCIDENT ee Ili NATURE OF DENT NATURE DE L INCIDENT 1 C Sports injury Blessure sportive 2 C Assauit Agression 4 C Other Autre 3 O Slip or fall Glissade ou chute Description 5 C Rough Play Jeu brutal D GymnasiunvGymnase CORRE Field tripExcursion 4 Sidewalk Trottoir School yard Terrain de joux CIS Washroom Toilette Parking Lot Terrain de stationnement C ia Slide Glissoire LI Shop Atelier LJ BBB Driveway All e Swings Balangoira CI Climber Grimpeur CO other Autro sisi ii essieu ses isissssesssssss DID INCIDENT OCCUR ON SCHOOL BOARD PREMISES EST CE QUE L INCIDENT S EST PRODUIT DANS LES LOCAUX DU CONSEIL SCOLAIRE LIYES OUI Lnonon IF NO GIVE FULL ADDRESS OF INCIDENT SITE SI NON VEUILLER DONNER L ADRESSE COMPLETE DU LIEU DE L INCIDENT V ION O
9. T FOR THE ADMINISTRATION OF EMERGENCY MEDICATION Student s Name Student Number SECTION 2 DOCTOR S APPROVAL FOR THE ADMINISTRATION OF EMERGENCY MEDICATION IN THE SCHOOL 1 Diagnosis 2 Reason 3 When should the medication be administered 4 Where should the medication be administered 5 Additional directions 6 The parent s guardian s of the above named pupil have requested the Dufferin Peel Catholic District School Board to offer a service for the administration of medication in an emergency to their child in the school The Board requires a Doctor s approval before implementing such a program Your signature below will provide the required approval with the following specific directions if any e g refrigeration reactions APPROVE THE ADMINISTRATION OF EMERGENCY MEDICATION AS DESCRIBED ABOVE FOR Student s Name Doctor s Name Doctor s Signature Date SECTION 3 DUFFERIN PEEL CATHOLIC DISTRICT SCHOOL BOARD STAFF APPROVAL FOR IMPLEMENTATION The administration of emergency medication in an emergency will be implemented as described above At the same time school personnel will contact emergency ambulance services Principal s Signature Date MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT Personal information on this form is collected under the legal authority of the Education Act R S O 1980 c 129 This inform
10. ahini tachini crayfish bass cottonseed shrimps bluefish caraway prawns carp mustard lobster anchovy flaxseed 21 514 02 APPENDIX I 2 OF 2 SHELLFISH continued snails oysters octopus scallops squid abalone cockle conch mussels clams preservative added to which causes a reaction dithionite metabisulplite bisulphite metabisulphite bisulphite NOTE These lists may change and are in no way complete FISH catfish cod eel flounder haddock halibut herring macherel marlin perch pickerel pike salmon sardine sole snapper smelt swordfish trout whitefish 514 02 SEEDS poppy seed psllium psyllium SULPHITE is a many foods chemical sodium sodium sodium sulphite potassium potassium sodium sulphur dioxide sulphurous acid 22 514 02 514 02 APPENDIX J Insect Sting Anaphylaxis The stinging insects that most often cause reactions anaphylaxis are bees wasps yellow jackets and hornets fal following are some coping suggestions for peak season Summer early fall Avoid where insects nest such as bushes and trees Do not walk barefoot or with open toed shoes Avoid garbage cans Make sure you are covered up when going outside Do not wear bright colours or flowery patterns Do not wear any kind of fragrance Stay away from open or uncovered food and drinks If one lands on you do not swat it brush it away or wait until it goes awa
11. ation will be used for the purposes of providing health and safety in the event of an emergency Questions regarding the collection should be directed to the Principal May 2011 Distribution __ Anaphylactic File OSR _____ Parent Guardian 14 514 02 514 02 GF400 D APPENDIX D Board Letterhead EMERGENCY ALLERGY ALERT FORM EPI PEN ONLY Name Address Home Telephone Emergency Phone Parent Guardian Work Phone Parent Guardian Work Phone Teacher Class Physician Physician s Telephone ALLERGY DESCRIPTION This pupil has a DANGEROUS life threatening allergy to the following items and to all foods containing them in any form in any amount AVOIDANCE The key to preventing an emergency is ABSOLUTE AVOIDANCE of these foods NOTE WHAT ABOUT OTHER ALLERGEN CAUSES WITHOUT AN EPI PEN THIS PUPIL MUST NOT BE ALLOWED TO EAT ANYTHING EATING RULES List eating rules for pupil if any in this space POSSIBLE SYMPTONS Flushed face hives swelling or itchy lips tongue eyes Difficulty breathing or swallowing wheezing coughing choking Dizziness unsteadiness sudden fatigue rapid heartbeat Tightness in throat mouth chest Vomiting nauseau diarrhea stomach pains Loss of consciousness ACTION EMERGENCY PLAN At sign of difficulty e g hives swelling difficulty breathing Use Epi Pen immediately HAVE SOMEONE CALL AN AMBULANCE to ad
12. dly speak to your child about the severity of this allergy e We have informed the student body of the problem and have asked them not to share their lunches snacks or treats We recognize that for some parents guardians this may be difficult to accommodate Please contact your son s daughter s teacher for alternatives Thank you for your assistance in making your school a safe environment for all pupils Sincerely Teacher 35 APPENDIX V ANAPHYLAXIS DIVISION OF RESPONSIBILITIES FOR PARENTS GUARDIANS PUPILS SCHOOL PERSONNEL ENSURING THE SAFETY OF PUPILS WITH AN ANAPHYLACTIC ALLERGY IN A SCHOOL SETTING DEPENDS ON THE COOPERATION OF THE ENTIRE SCHOOL COMMUNITY TO MINIMIZE RISK OF EXPOSURE AND TO ENSURE RAPID RESPONSE TO EMERGENCY PARENTS PUPILS AND SCHOOL PERSONNEL MUST UNDERSTAND AND FULFILL THEIR RESPONSIBILITIES RESPONSIBILITIES OF THE PARENTS GUARDIANS OF AN ANAPHYLACTIC CHILD e Inform the school of their child s allergies e Provide a medic alert bracelet for their child e Provide the school with physician s instructions for administering medication e Provide the school with up to date injection kits and keep them current e Provide support to school and teachers as requested e Provide in service for staff if requested e Participate in parent advisory support groups e Assist in school communication plans e Review the school action plan with school personnel e Supply information for school publications e
13. e foods for classroom events Establish procedures to ensure that the pupil with an anaphylactic allergy eats only what he she brings from home Reinforce hand washing before and after eating Facilitate communications with other parents guardians Follow the Board s procedures for reducing risk in classrooms and common areas see section 3 Avoidance Enforce school rules about bullying and threats Leave information in an organized prominent and accessible format for substitute teachers Ensure that the auto injectors are taken on field trips RESPONSIBILITIES FOR PUBLIC HEALTH Consult with or act as a resource and provide information to parents guardians pupils and school personnel Participate in planning Board policy and procedures RESPONSIBILITIES OF ANAPHYLACTIC PUPILS AS AGE APPROPRIATE FOR THE STUDENT Take as much responsibility as possible for avoiding allergens Eat only foods brought from home Take responsibility for checking labels and monitoring intake older pupils Wash hands before eating Learn to recognize symptoms of an anaphylactic reaction Promptly inform an adult as soon as accidental exposure occurs or symptoms appear Take responsibility for keeping their auto injector with them at all times 38 APPENDIX W ANAPHYLACTIC RESOURCES 1 SABRINA S LAW KIT Green Plastic Box From Ministry January 2006 2 REGION OF PEEL SCHOOL HEALTH MANUAL UPDATED ANAPHYLACTIC RESOURCES amp MEMO 3 ANAPHYL
14. eas using co operative approach with pupils and parent s guardian s Develop strategies for monitoring the above area and for identifying high risk areas for anaphylactic pupils Last resort provide safe eating area for pupils with an anaphylactic allergy Lunchroom Eating Area Procedures Pupils should not wander with food i e to and from garbage leave waste lunch on their desk Require anaphylactic pupils to eat only food prepared at home or approved for consumption Discourage sharing food utensils Mealtime precautions consistent place and clean area food placed on waxed paper napkin and pack up lunch leaving it with supervisor if leaving room washroom break Establish hand washing routine before and after food time If hand washing is not possible no sink in classroom use wet wipes If there is a cafeteria or lunch snack provider keep allergens off menu Where possible tables and other eating surfaces should be washed after eating Vending machines are considered a service for the school community which may include milk and or other products and which are consistent with the Ministry of Education s School Food and Beverage Policy PPM 150 Vending machines must be clearly labelled or contain warnings with respect to their contents and that appropriate procedures should be put in place to minimize contact by students with allergies to such products Hidden Allergens Play dough beanbags st
15. ettings and for secondary school age pupils as they travel further from home as they are extremely vulnerable to peer influences and as they may at this stage of development deny their vulnerability Secondary schools should follow the following guidelines Secondary school pupils should carry the proper prescribed amount of medication on their person Secondary school staffs should consider arranging presentation of information on allergy and anaphylaxis through the academic program or through a school wide assembly Secondary school pupils who are subject to anaphylactic reaction should be aware that foods with allergens may be served in the school cafeteria Cafeteria staff should also be aware of anaphylactic pupils and educated about anaphylaxis C ACTION EMERGENCY RESPONSE PLAN Every School Principal must develop an individual plan for every known pupil who has an anaphylactic allergy Every individual plan will include Communicate emergency A S A P to Epi Pen trained staff member Administer epinephrine Call 911 or an ambulance inform operator that student having anaphylactic reaction If no ambulance transport by car one adult as well as driver If possible call hospital to inform of situation If transported by car inform police of make and license Call parent guardian emergency contact Re administer Epi Pen every 10 20 minutes while on route if individual experiences a bac
16. ff and volunteers have received instruction with the auto injector Ensure that substitute teachers are informed of the presence of a pupil with an anaphylactic allergy and have been adequately trained to deal with an emergency Inform all parents guardians that a child with life threatening allergies is attending the school and ask for their support sample letters and newsletter attached in Appendix A B C Arrange for appropriate in service At least annually if there are anaphylactic pupils Develop an emergency protocol for each pupil with an anaphylactic allergy see Appendix D Maintain an auto injector trainer in medical supply area Store auto injectors in easily accessible locations Establish safe procedures for field trips and extra curricular activities see section 3 Avoidance Field Trips Implement Board procedures for reducing risk in classrooms and common areas see section 3 Avoidance Establishing Safe Lunchroom and Eating Procedures Enforce disciplinary procedures for dealing with bullying and threats 37 RESPONSIBILITIES OF THE CLASSROOM TEACHER AS AGE APPROPRIATE FOR THE STUDENT Display a photo poster in a classroom with parental approval sample attached from Administrative Procedures Administration of Prescribed and Emergency Medication Section 01 16 00 Appendix F Discuss anaphylaxis with the class in age appropriate terms Encourage pupils not to share lunches or trade snacks Choose allergy fre
17. hreatening Anaphylaxis anna fill axis is potentially a life threatening allergic reaction which involves several body systems skin upper and lower respiratory gastro intestinal and cardiovascular It can cause many different symptoms Life threatening components include those involving the airway and blood circulation The goal of the board s policy is to provide a safe environment for pupils with life threatening allergies recognizing that it is not possible to reduce the risk to zero In Canada anaphylaxis is estimated to affect 1 to 2 of the population about 600 000 people Accidental administration of Epinephrine medication if a reaction is not actually taking place is not a cause for concern according to the Canadian Paediatric Society In young patients serious adverse effects of epinephrine such as cardiac arrhythmias and hypertensive crisis are extremely rare and the life saving benefit of injecting epinephrine in cases of suspected anaphylaxis outweighs any small risk of side effects Causes Common causes are food insect stings e g yellow jacket wasps and medication Other causes are latex exercise usually in conjunction with ingestion of a food and immunotherapy allergy shots Food Allergies Food accounts for approximately 50 of all anaphylactic reactions and this proportion is probably higher in children Any food can cause anaphylaxis but in North America nine foods account for more
18. hreatening allergies but it is not possible to reduce the risk to zero The Dufferin Peel Catholic District School Board s policy requires prior to administration of prescribed medication to your child by school staff that the Request and Consent for the Administration of Epinephrine Form must be completed and returned to the school principal prior to your child starting school EMERGENCY TREATMENT FORMS Enclosed are three blank Anaphylaxis Emergency Treatment Forms Please complete the information requested and return along with a recent photo of your child Please ensure that the picture is a minimum of 2 x 3 with only a head and shoulder shot The Emergency Allergy Alert Form containing your child s picture will be posted in the Health Room INFORMATION RESPONSIBILITIES OF PARENT GUARDIAN RESPONSIBILITIES OF PUPIL WITH ANAPHYLAXIS Please refer to the attached forms Kindly ensure that you go over the student responsibilities form with your child If you have any questions please direct them to the principal during the last week in August or prior to your child starting at the school 514 02 514 02 MEDICINE TO BE ADMINISTERED LIFE THREATENING ALLERGIES Epi Pen We request that you provide two 2 containers one your child will carry with her him JK SK pupils will have it located in classroom the second will be located in a central location office health room for easy access
19. ian and or principal informs school bus driver see Appendix P 28 APPENDIX O Checklist Annual Timeline for Schools with Anaphylactic Pupils SEPTEMBER Principal to Distribute all class materials folders files to receiving teacher Meet with and brief receiving staff including secretaries custodians day night Check with parent guardian regarding changes over the summer Check EpiPen and other medications re expiry dates and location Post emergency allergy alert form see Appendix D Identify all pupils at initial staff meeting of all staff or hold special meeting re all anaphylactic pupils Review administration of EpiPen including practice EpiPen Review emergency procedures for each staff member Review 911 procedures and locations of all medications Review and up date literature emergency folders student photos Teacher ensures presence of emergency file for anaphylactic student Teachers of Anaphylactic Pupils Review Emergency Plan Review key components of student file Review occasional teacher folder Review location of all medications Establish class cleanup routines wipe down desks Distribute information letter to school community Provide parent guardian with communication package Appendix V 29 APPENDIX P ANAPHYLAXIS PROTOCOL for Transportation The protocol should consist of the following Initial 6 hours training of emergency management CPR and first aid training including EpiPen trai
20. icy Exercise caution when commiting to fund raising companies to ensure that identified anaphylactic allergens are not contained in the products sold by school community 32 APPENDIX S Dufferin Peel Catholic District School Board Office of the Director of Education LETTER OF INDEMNITY September 2008 All Employees of the Dufferin Peel Catholic District School Board With respect to the Anaphylaxis protocol the following letter of indemnification shall apply If an employee administers medication to a student in an emergency situation the Dufferin Peel Catholic District School Board shall at all times indemnify and save harmless the employee from and against all claims demands reasonable related legal costs damages actions suits or other proceedings for bodily injury including death arising from anything negligently done or anything negligently omitted by the employee acting in good faith in administering or failing to administer the medication Yours truly John Kostoff Director of Education Revised August 2008 33 APPENDIX T School Letterhead ANAPHYLACTIC REACTION Sample Reminder Thank You Letter Dear Parent s Guardian s Re Peanut Allergies The pupils in our school with severe food allergies that are life threatening and their families would like to join me in thanking you for your understanding and cooperation as a result of the request to avoid sending peanut a
21. ild self administer Ask parent guardian for history of previous reactions actions taken Complete name forms see Appendix A B C and D Complete Emergency Allergy Alert Form D Parent verifies emergency Allergy Alert Form D Student Verification Form elementary Short Index secondary Information is entered in Notes section and in Medic Alert Section l J enter information into OSR regarding allergy Prepare Substitute teacher folder Determine location for primary and for backup medication child should carry EpiPen if possible time being of the essence when determining location for EpiPen and back up Parent guardian supplies photo s of child Arrange for meetings with staff and parents guardian s Place on agenda of staff meeting or call special staff meeting semi annually Review Collective Agreement with specific reference to administering medical procedures Office staff responds immediately to public address call Prepare letter to school community See Appendix G Determine lunchroom practices with parent first preference child eats lunch at home e g hand washing desk washing ventilation floor garbage disposal and cleaning Schedule a school assembly and or classroom information session Determine procedures for the arrival of unexpected food discourage outside food where possible Organize session on hand washing Newsletter reminders Halloween Christmas Easter see Appendix H Parent guard
22. is may or may not affect your child s class directly please send foods with your child to school that are free from peanuts or nut products There will be more information about anaphylaxis shared throughout the school year ie newsletter class letters website Thank you for understanding and cooperation 514 02 514 02 APPENDIX 1 of 2 FOODS THAT CAN CAUSE AN ANAPHYLACTIC REACTION Any food can cause a reaction to someone Anyone can be or become anaphylactic to ANY food at anytime throughout their lifetime The ten most common food allergens are peanuts tree nuts milk eggs wheat seeds fish shellfish soybean and sulphite The following lists are some alternative names that may be found on labels PEANUT TREE NUT WHEAT cold pressed peanut oil walnut couscous ground nuts almonds gluten nut meats brazil nuts farina mandelonas cashews durum wheat arachis oil chestnuts wheat bran goober nuts pecans wheat germ nu nuts hazelnuts graham flour pine nuts bulgar shea nuts semolina macadamia nuts spelt pistachios kamut hickory nuts pinion EGG MILK SOYBEAN ovalbumin whey soya globulin curds hydrolyzed soy protein lecithin from egg casein soy protein albumin caseinates tofu conalbumin milk ingredients soja lysozayme milk solids ovomucin modified milk ingredients vitellin lactbumin ovovitelin lacto globin vomucoid lactos is a milk sugar not a milk protein livetin SHELLFISH FISH SEEDS crab tuna sesame t
23. kward slide in condition i e worsens Keep dispensed Epi Pen Complete OBSIE form see Appendix E Location of Epi Pens Covered secure accessible area As soon as mature enough pupils should also carry their own Up to date supply provided by parents guardians in unlocked area of classroom and or central area Number depends on estimated time to medical facility All staff to know locations of Epi Pen
24. l to keep up to date record of staff who received in service in use of EpiPen and the Board will keep records for occasional teacher Complete Appendix Q September of each year for staff sign off re training Sharing Information with Other Pupils With permission of parent s guardian s this should be done in such a way as to reduce chance of teasing threatening bullying etc Sharing Information with Parents Guardians and Parent Groups Develop communication strategy i e school class newsletters community information sessions etc At the start of the school year semester a letter should be sent to parent s guardian s explaining the food allergy and how parent s guardian s community can keep pupils safe see Appendix and G Provide suggested alternatives to food allergens Any student with food allergy should not eat foods other than those sent from their home Follow up reminders throughout year see Appendix T Suggestions on what to do if pupils continue to bring allergen to school reminder of danger letter to home requesting co operation calling offending families asking for consideration GAP 514 02 Page 6 requiring student with allergen to eat away from anaphylactic student Fall back plans should be developed before school year starts Maintain Open Communication B AVOIDANCE Providing Allergen Aware Areas Where Possible Establish classrooms as allergen aware ar
25. ld on field trips if possible Inform the school bus driver about your child s medical needs Keep up to date if driver changes Verify all posted information about your child Inform school staff of any allergic reactions that occur outside of school hours 514 02 514 02 APPENDIX L Student Poster Template Attention THERE ARE STUDENTS IN THIS ROOM WITH LIFE THREATENING ALLERGIES TO THE FOLLOWING ALLERGENS PLEASE DO NOT BRING ANY ITEMS INTO THIS CLASSROOM THAT CONTAIN Student Poster Template PICTURE OF STUDENT Attention Pupils with Allergies If you have any food allergies such as peanuts nuts eggs milk wheat shellfish fish soybean seeds sulphites Remember If you are not sure or have no epi pen DON T EAT IT 26 APPENDIX M Poster How to Use the EpiPen Auto Injector How to use the x other Auto Injector Comment utiliser l auto injecteur d adr naline EpiPen en trois tapes simples Sites yt rece a Locations staff handbook supply teacher handbook office PLASP staff room bus driver Health Room 27 APPENDIX N School Action Plan Checklist Description from parent guardian outlining allergens preferably in order of severity Statement medical history related unrelated medical conditions e g asthma completion of forms 400 B C D Degree of awareness of child maturity Medication required Can ch
26. nd nut products to the school There has been a reduction in the number of peanut and nut products brought to school in snacks and lunches and we would like to thank you for continuing to avoid sending these products to school with your child Since even a minute amount of the allergic substance can cause a life threatening reaction keeping it out of the classroom is our best method of preventing a serious reaction at school If your child does bring a food to school containing peanut or nut products please ask the child to let the teacher know Thank you again for your cooperation in this important issue Sincerely Principal Schools will need to substitute if anaphylactic allergen differs milk egg wheat soy fish shellfish 34 APPENDIX U School Letterhead ANAPHYLACTIC REACTION SAMPLE LETTER TO CLASSROOM PARENT S GUARDIAN S FROM TEACHER Dear Parent s Guardian s of Pupils in Grade A child in our class has extreme allergies to This also includes any food that contains peanuts or peanut products The allergy of this student is so severe that it could be life threatening he she may have a reaction if any item containing peanuts is even in close proximity All staff have been informed of this situation and have been instructed in the correct procedure regarding anaphylactic reaction e We need your cooperation in refraining from sending these food products to school with your child e Kin
27. ning and annual refreshers Both the principal and the parent guardian should identify the child to the school bus company 30 APPENDIX Q STAFF INSERVICE OF ANAPHYLAXIS PROTOCOL AND GUIDELINES A School Plan of Action for Anaphylaxis Protocol and Guidelines is recommended that the school principal review the document with all school staff at a staff meeting early in the school year September October It is also recommended that the principal meet with the parent s guardians s of pupils diagnosed with Anaphylaxis upon registration at the school and or upon diagnosis of Anaphylaxis as outlined in A School Plan of Action for Anaphylaxis Protocol and Guidelines Principals are asked to complete this form and retain for future reference Name of School Date of inservice to staff Inservice suggestions to staff include a general review of the document and view and discuss Taking Control Food allergies and You video See resource list Specific roles of the administration in providing plan of administration of medication to pupils with an anaphylactic allergy Choices that staff members have in providing the safest environment to themselves and to pupils A review of procedures that staff are to follow when a student is experiencing Anaphylactic shock Staff Inservice September October Signature of Principal Date Staff Signature s Attach page for additional staff signatures 31 APPENDIX
28. ou see it Reassure the student that you are aware of his her needs and that you know how to keep him her safe Train the student to self advocate regarding their allergy e g how to approach an adult Ensure that EpiPen is kept with the student or supervising teacher at all times Be aware that there are cases of pupils with an anaphylactic allergy being threatened with the allergen by bullies School staff shall deal with such a situation as a serious incident Do not hesitate to contact the student s parents or other sources for further help and information Fundraising Activities The Dufferin Peel Catholic District School Board requires that the health and safety of the entire school community be foremost in any decisions regarding School fundraising activities There will be no fundraising events that include life threatening allergens such as peanuts peanut by products tree nuts fish milk egg soy sesame seed shellfish and wheat Administrators need to identify other life threatening allergens of student population milk cheese and ensure that student s safety is not compromised 18 514 02 514 02 APPENDIX G September Anaphylaxis Letter As we begin a new school year we would like to inform you that Elementary Secondary is an allergen aware school There are pupils in attendance who suffer from severe and life threatening allergies to certain foods such as peanut and nut p
29. r each pupil who has an anaphylactic allergy of current treatment and other information including a copy of any prescriptions and instructions from the pupil s physician or nurse and a current emergency contact list Contents of an individual plan must include Details informing employees and others who are in direct contact with the pupil on a regular basis of the type of allergy monitoring and avoidance strategies and appropriate treatment A readily accessible emergency procedure for the pupil including emergency contact information See Appendix D Storage for epinephrine auto injectors where necessary Responsibility of parent s guardian s to identify to the school and provide information re foods that trigger treatment protocol signed by pupil s physician any changes in pupil s condition from previous years and permission to post photos and medical info in key locations e g classroom health room staff room etc Pupil with an anaphylactic allergy should be identified in elementary secondary transition Encourage all pupils with an anaphylactic allergy to always carry epinephrine on their person Epi Pen and to wear a medical alert identification Identification to All Staff All staff teaching and non teaching shall be made aware of pupils with an anaphylactic allergy at first staff meeting or as early in school year semester as is possible Policy to be reviewed with all staff bus drivers vol
30. recipes e foods to avoid e alternate snack suggestions and e resources e Be willing to provide safe foods for special occasions e Teach their child e to recognize the first symptoms of an anaphylactic reaction e to know where medication is kept and who can get it e to communicate clearly when he or she feels a reaction is starting e to carry his her own auto injector in a fanny pack e not to share snacks lunches or drinks e to understand the importance of hand washing e to cope with teasing and being left out e to report bullying and threats to an adult in authority and e to take as much responsibility as possible for his her own safety e Welcome other parents calls and questions about safe foods 36 RESPONSIBILITIES OF THE SCHOOL PRINCIPAL AS AGE APPROPRIATE FOR THE STUDENT Work closely as possible with the parents guardians of a pupil with an anaphylactic allergy Ensure that the parents guardians have completed all the necessary forms sample attached from Administrative Procedures Administration of Prescribed and Emergency Medication Ensure that instructions from the child s physician are on file Notify the school community of the anaphylactic child the allergens and the treatment Post allergy alert forms in the Health Room sample attached from Administrative Procedures Administration of Prescribed and Emergency Medication Maintain up to date emergency contacts and telephone numbers Ensure that appropriate sta
31. request and consent to the injection of epinephrine Epi Pen Parent Guardian Print Name Signature Date TO BE COMPLETED BY THE PARENT S GUARDIAN S SECTION C Student s Name Please List Specific potentially life threatening allergens Please indicate the nature of the reaction check all applicable Physical contact with this allergen may cause an anaphylactic reaction Airborne contact with this allergen may cause an anaphylactic reaction Ingestion of food may cause an anaphylactic reaction Other Please explain below Recommended treatment in the event of accidental exposure Parent Guardian Print Name Signature Date NOTE THIS REQUEST WILL TERMINATE ON JUNE 30 OF EACH SCHOOL YEAR MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT Personal information on this form is collected under the legal authority of the Education Act R S O 1980 c 129 This information will be used for the purposes of providing health and safety in the event of an emergency Questions regarding this collection should be directed to the Principal August 2006 12 514 02 514 02 Distribution _ Anaphylactic File OSR ____ Parent Guardian GF400 C APPENDIX C Board Letterhead SCHOOL RECORD OF MEDICAL SERVICES Student Name Student Number Surname First Date of Birth Year Month Day School Grade Placement
32. roducts Exposure to the smallest quantities can cause severe life threatening reactions Anaphylaxis is a severe and life threatening allergic reaction The most common allergen triggers are food insect stings mediations exercise and latex An anaphylactic reaction involves symptoms from two or more body systems Safety of all of our students is paramount We at would appreciate the co operation of the entire school community by NOT sending any lunches or snacks that contain the list of food products attached which could potentially harm a pupil Please make sure that all of your children s caregivers are aware of the food restrictions Please avoid sending food for birthday or special occasions There are many alternatives such as stickers and pencils If you have any questions please talk to your child s teacher or the school staff We look forward to our co operation in making this a safe year for all our pupils NOTE schools will need to personalize life threatening allergy ie peanut and nut products milk egg soy wheat fish shellfish 514 02 514 02 APPENDIX H ANAPHYLACTIC REACTION SAMPLE NEWSLETTER We felt that all parents would like to be aware that there is a pupil or several pupils in school with a severe life threatening food allergy anaphylaxis to peanuts and nuts This is a medical condition that causes a severe reaction to certain allergens and can result in death within minutes Although th
33. than 90 of all reactions These are peanut tree nuts shellfish fish milk egg soy sesame seed and wheat Sulphite while not a food is considered a major allergen by Health Canada Often found in processed foods and beverages it can trigger an allergic reaction in sulphite sensitive people In North America peanut and tree nuts have caused the greatest number of food related deaths in children It is important to provide safeguards for all children with other life threatening allergies including milk egg sesame seed etc Parents guardians are encouraged to work with Dufferin Peel Catholic District School Board staff to develop specific avoidance strategies GAP 514 02 Page 3 Fundraising Activities The Dufferin Peel Catholic District School Board requires that the health and safety of the entire school community be foremost in any decisions regarding School fundraising activities Administrators need to identify life threatening allergens of the student population peanut seafood eggs dairy tree nuts soy shellfish wheat sesame seeds and so forth and ensure appropriate accommodations so that student s safety and well being is not compromised The benefits and the risks of such fundraising must be carefully considered Consultation with the adult student and or parent guardian of the anaphylactic student shall occur in order to ensure that the appropriate accommodations are in place to protect the student from e
34. ty Bus operators must be informed of presence of pupils with an anaphylactic allergy and drivers must be trained in emergency response procedures Develop risk reduction and individual emergency response plan which accounts for route and distance from medical help Establish buddy system to watch for unusual behaviour Designated seating placement for pupils with an anaphylactic allergy No Food Drink Policy Insect Stings Precautions Avoid colourful loose fitting clothes newsletter inserts Regular inspection for bees and wasps and removal thereof Ensure garbage properly covered No food outdoors at recess elementary panel Allow pupils with an anaphylactic allergy to remain indoors during high risk times Remove anaphylactic student if bee or wasp enters room Any open windows should have screens OK XX XX XX 514 02 514 02 APPENDIX A Dear Parent s Guardian s Re Administration of Epinephrine Epi Pen for Life Threatening Allergy To be prepared for your child s medical needs on his her first day of school we request that you complete the attached forms and return them to the school during the last week of August prior to your child beginning school Please make an appointment to review your child s needs with the principal and your child s classroom teacher ADMINISTRATION OF EPINEPHRINE EPI PEN The goal of the board s policy is to provide a safe environment for children with life t
35. uffed toys sand water tables counting aids beans peas science projects seasonal activities Easter Eggs Fund raising activities Pupils with an anaphylactic allergy should not participate in recycling school clean up Allow pupils with an anaphylactic allergy to keep the same locker desk all year Year end clean up of lockers desks etc essential GAP 514 02 Page 7 Holidays Celebrations Encourage non edible treats Food to be shared not recommended for allergic pupil must have list of ingredients Pupils with an anaphylactic allergy to provide own treat from home may be frozen and kept for other occasions Excursions Include serious medical conditions section in trip manifests Require all supervisors to be aware of pupils with an anaphylactic allergy allergens and treatment Ensure staff parent s guardian s have a cell phone in case of emergency Require parent s guardian s of pupils with an anaphylactic allergy to provide two three Epi Pens to be administered if individual experiences a backward slide in condition i e worsens every 10 20 minutes on route to hospital If risk too great consult with parents guardians NOTE For class trip school should reconsider destination Supply Teachers Volunteers Others Require regular teacher to leave info re pupils with an anaphylactic allergy with emergency procedures outlined and if possible involve them in in services Bus Safe
36. unteers etc who come in contact with pupil Allergy alert form with photo description of allergy and treatment plan should be in student s files and posted in Health Room Identification in Trillium Share with parent s guardian s where information will be posted Instructions on symptoms emergency procedures and Epi Pen use should be posted and visible in key locations GAP 514 02 Page 5 In Service School Board to ensure that in service is provided by either board or school staff to school office staff teachers occasional teachers clerical staff ERWs school bus drivers custodians cafeteria staff volunteers and others who may come in contact with pupils with an anaphylactic allergy The in service is to focus on recognition of anaphylactic reaction emergency procedures and board policies to protect student from exposure to allergen All staff in position of responsibility for pupils with an anaphylactic allergy must be trained in the use of the Epi Pen Trainer and view and discuss video Taking Control Food Allergies and You Administrators connect with community health partners and the Community Care Access Centre CCAC for special needs pupils Parents Guardians responsible to ensure specific info on their child is made available to school staff including allergens and symptoms for their child Information regarding allergens should be shared i e newsletter Schoo
37. vise the dispatcher that the pupil is having an anaphylactic reaction If ambulance has not arrived in 15 20 minutes and symptoms reappear or become worse give a second Epi Pen Even if symptoms subside entirely this pupil must be taken to the hospital immediately EPI PENS are kept in Classroom lunchroom staff room office with student MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT Personal information on this form is collected under the legal authority of the Education Acf R S O 1980 c 129 This information will be used for the purposes of providing health and safety in the event of an emergency Questions regarding this collection should be directed to the Principal 514 02 514 02 August 2008 Distribution ___ Anaphylactic File OSR Post Original in Health Room APPENDIX E SCHOOL BOARD LOGO ONTARIO SCHOOL BOARDS INSURANCE EXCHANGE FONDS D ECHANGE D ASSURANCE DES CONSEILS SCOLAIRES DE L ONTARIO INCIDENT REPORT FORM RAPPORT D INCIDENT APPENDIX E Complete Incident Report Online This is the preferred method to report incidents accidents involving students visitors guests and volunteers Each school has been provided with a USER MANUAL clear pink duo tang with the online procedures including a common user name and password for Dufferin Peel CDSB If necessary fax within 24hours of incident FAX 519 767 0281 514 02 514 02 5 PLEASE TYPE OR PRINT S V P DACTYLOG
38. xposure to any products containing allergens that are brought into the school for fundraising purposes As appropriate consultation with the Catholic School Council will occur Create A Safe Environment 7 Know which pupil staff have allergies Encourage allergic individuals to always carry epinephrine on their person e g Epi Pen and wear Medic Alert identification Inform the community about anaphylaxis x Have parent s guardian s complete an anaphylaxis emergency protocol form with information specific to the pupil including his her photo See Appendix D Emergency Allergy Alert Form Encourage self advocacy of pupil with anaphylactic allergens Know the Signs and Symptoms Think F A S T F Face itchiness redness swelling of face and tongue A Airways trouble breathing swallowing or speaking S Stomach stomach pain nausea vomiting diarrhea T Total hives rash itchiness swelling weakness pallor paleness sense of doom loss of consciousness Treatment Despite best efforts accidents can happen Epinephrine e g Epi Pen is the medication of choice in the treatment of an anaphylactic reaction Given the rapidity with which symptoms can develop and progress epinephrine must be available immediately GAP 514 02 Page 4 PROCEDURES 3 A s AWARENESS AVOIDANCE ACTION A AWARENESS Identification of Anaphylactic Pupils The Principal must maintain a file GF400A Red Folder for OSR fo
39. y on its own Latex Allergy Latex is a hard substance to avoid because you cannot tell by looking at something whether it is latex rubber or a manufactured rubber The following is a list of some products that may contain latex erasers tape adhesives craft supplies seasonal crafts special occasions diapers underwear balloons soccer balls volleyballs basketballs rubber toys band aids first aid tape medical gloves Carpet backing mats rubber foam rubber rubber gloves for cleaning Children with certain medical conditions and people working in the medical dental profession may become allergic 23 514 02 514 02 APPENDIX K Checklist for Parent s Guardian s of an Anaphylactic Student Arrange meeting with principal to exchange information Notify school personnel of your child s allergens in order of severities Complete The Request and Consent Form for the Administration of Epi Pen in an Emergency Form see Appendix B Provide the school with required number of EpiPens and make sure they are not expired Consider a Medic Alert bracelet for your child Educate yourself about foods that can cause anaphylactic reactions Stress with your child and the school staff that only foods from his her home are to be eaten Keep up to date about education and new information in this field Research field trip sites for allergen risks Accompany your chi
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