(Rev.

8/03)

EMERGENCY PLAN FOR INDIVIDUAL STUDENT*

Student Name: SHADAYE BYFIELD
School: OLHS
Teacher:
Classroom or Grade: 1OTH
School Year: 2014/2015
Medical Condition: ALLERGIC TO PEANUTS, SHELLFISH, BANANAS, & TREENUTS
***********STUDENT SELF CARRIES EPI-PEN****************
School Nurse Signature: Cate Baker, RN
Child-Specific Emergencies:

If You See This:

ALLERGIC REACTION: itching, hives,

Do This:
Remain calm and stay with student

rash

Call clinic ASAP #85557/85558 give name of

swelling of face, mouth, tongue, lips, trouble

student, location and problem.

swallowing, shortness of breath, extreme

Student knows how to give Epi Pen or nurse

anxiety

will administer Epi Pen

NURSE WILL: Call 911
Call parent or parent designee

If an emergency occurs:
1.
2.

Stay with student.

Call or designate someone to call the nurse.
State who you are:
State where you are:
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(Rev. 8/03)

3.
4.

State problem:
The school nurse will assess the student and decide whether the emergency plan
should be implemented.
If the school nurse is unavailable, the following staff members are trained to deal
with an emergency and to initiate the emergency plan:
Shannon Karus, LPN
Nina Ransom CNA

*Adapted from Project School Care Guidelines for Care, Boston Childrens Hospital, Boston,
Massachusetts

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