ࡱ> 3P29 bjbj@@ x *h*h  2228j$2T$:,$4$0TV V V TV  X : Ϻ Bucks School District Competency Check List for Student Self Administration of Epinephrine Auto-injector Name_____________________ GR_______ HR___ Effective: 20__- 20__ Parent/guardian must supply physician orders for self administration and all necessary equipment and supplies. To self medicate, the student must be able to: (check all that apply) ____ 1. Respond to and visually recognize his/her name. ____ 2. Identify his/her medication. ____ 3. Recognize and verbalize on the signs and symptoms of anaphylaxis. ____ 4. Demonstrate the proper technique for self-administering his /her medication. ____ 5. Verbalize that he/she needs to report to an adult or to the nurse immediately after using the Epinephrine. ____ 6. Demonstrate a cooperative and responsible behavior in all aspects of self-administration of medication. ____ 7. Encourage additional medication in the nurses office. _____________________ ________ _____________ Name of Medication Dosage Frequency The above named student has demonstrated the ability to self-administer the physician-prescribed medication as indicated by the criteria listed above. ___________ _________________________________ Date Nurse Signature As the parent/guardian of above named student, I relieve the school district and its employees of any responsibility for the benefits or consequences of the above listed medication when it is physician-prescribed and parent/guardian authorized. I further acknowledge the school bears no responsibility for ensuring that the medication is taken. I am aware that any improper use or sharing of the above named medication will result in the immediate confiscation of the Epinephrine Auto-injector and loss of privilege to self-administer if the medication policy is violated. ___________ ____________________________ Date Parent/Guardian Signature I agree to be responsible for my Epi-pen and follow the directions for its use as ordered by my physician, as well as the districts medication policy. I am aware that any abuse of this privilege will result in the confiscation of my Epinephrine Auto-injector. ___________ _____________________________ Date Students Signature     6Ko  & Q R ű|qbSA#hh'5CJOJQJ^JaJhWq5CJOJQJ^JaJhtO5CJOJQJ^JaJhhYCJaJhsS5CJOJQJ^JaJ#hhY5CJOJQJ^JaJ&hh/56CJOJQJ^JaJ&hh56CJOJQJ^JaJ hI 56CJOJQJ^JaJ h56CJOJQJ^JaJ#hh/5CJOJQJ^JaJ hh/6Q R S C D    !gdY &dPgdYgdY &dPgd/gdR S C D         " + , - u ԽԲԌԌԖԖԖ}n}}h'hpCJOJQJ^Jh'h[CJOJQJ^JhtOOJQJ^Jh'h[5OJQJ^Jh'hp5OJQJ^JhtO5OJQJ^Jh'hpOJQJ^JhI OJQJ^Jh'h[OJQJ^J hh[CJOJQJ^JaJh'CJOJQJ^JaJ+   , -   NO{ !       NO{p󼼭󼒼whZhFh[5OJQJ^Jh'hI CJOJQJ^Jh[CJOJQJ^JhI hI CJOJQJ^Jh'hFCJOJQJ^JhI CJOJQJ^Jh'h'CJOJQJ^Jh'h[CJOJQJ^Jhb0OJQJ^Jhb0hb05OJQJ\^Jh'h[5OJQJ^Jh'h[OJQJ^J!h q3jh q3Uh[v+p,p-p.p/R 4567:p3Z/ =!"@#$% x666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH 8`8 Normal_HmH sH tH DD  Heading 1$$@&a$ 5CJ\`@` / Heading 2$<@&$56CJOJPJQJ\]^JaJDA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List 2B@2  Body TextCJ4@4 Header  !4 4 Footer  !6P@"6  Body Text 2CJF>2F Title$R`]R^`a$ 5CJ\X/AX /Heading 2 Char$56CJOJPJQJ\]^JaJ@`R@ Y No Spacing_HmH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y #  R    8@0(  B S  ?1<+6333S3C MN&% 5I 0A#3Z< E ++b0 q3#-:g<XJtOZWqbj'F*p/.=x^np,N[68sSYd@0@UnknownG.[x Times New Roman5Symbol3. .[x Arial7$BCambriaC.,.{$ Calibri Light7..{$ CalibriA$BCambria Math"hvGvG;"gUU!203Q@P $PA#2!xxkd Central Bucks School DistrictMario L. CanalesREBSTOCK, LORI Oh+'0 ( H T ` lx Ϻ Bucks School DistrictMario L. CanalesNormalREBSTOCK, LORI2Microsoft Office Word@@n@T!#@T!#U ՜.+,D՜.+,h$ px  Gateway Document Ϻ Bucks School District Titlex :BContentTypeId,0x0101000A80FB4F94B5084DBAB36BBA68F7BDD8  !#$%&'()+,-./0145689:;<=>?@ABCDEFGHIJKLMNORSTUVRoot Entry Fq-$Q@ 1TableV WordDocumentx SummaryInformation("DocumentSummaryInformation8*MsoDataStore ,$,$CFT05CNUGXMB==209,$P,$Item 750Properties}ZGSTBRNUDRJP==2 09,$`,$Item  PropertiesO3SZPU3POL4RNAWP==2 09,$,$Item Properties!UCompObj'r This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision.   "#$%&( DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q