NOOR-UL-IMAN SCHOOL NURSING FORMS

Print the forms necessary for your child according to his/her grade level and return to the Nursing Office.

NOOR-UL-IMAN SCHOOLS, INC. A Non-Profit, Tax-Exempt Educational Organization Registered in the State of New Jersey

Accredited by the New Jersey Association of Independent Schools

Federal Tax-Exempt No. 22-3249506

4137 Route 1 South, Monmouth Junction, New Jersey 08852

Pre-K ONLY

Phone (732) 329-1800 Fax (732) 329-0161 High School Fax (732) 329-0193

TO: Parent/Guardian

FROM: Head of School RE: 2017-2018 Nursing Services for Pre-K Students ONLY

Noor-Ul-Iman School provides nursing services to students. Included in

these services is maintenance of student health records. In addition, your

child will receive emergency nursing services for any school related

illnesses or injury.

Please sign the form below and return it to the office.

NOOR-UL-IMAN SCHOOL NURSING SERVICES

I do give my permission

I do NOT give my permission

for my child _, in grade to (Pre-K 3 or Pre-K 4 Only) (First Name Last Name)

participate in nursing services.

Name of Parent/Guardian Printed

Signature of Parent/Guardian Date

Noor-Ul-Iman Schools, Inc. admits students of any race, color, religion, and national or ethnic origin.

MIDDLESEX REGIONAL EDUCATIONAL SERVICES COMMISSION and

NOOR-UL-IMAN SCHOOL 2017 - 2018

TO: Parent/Guardian FROM: Private School Principal RE: Grades KG - 12 Nursing Services: Chapter 226-Laws of 1991

Existing legislation provides certain nursing services and funding for full time students in private schools. In addition to the nurse provided by this funding, NUI hires two part-time nurses to help serve our large student body.

Included in nursing services is maintenance of student health records, hearing assessment, and vision screenings. Students in 5th, 7th, 9th and 11th grades will be screened for scoliosis.

In addition, your child will receive emergency nursing services for any school related illnesses or injury.

Please sign the form below and return it to the office.

NONPUBLIC NURSING SERVICES I do give my permission I do NOT give my permission

for my child________________________________, in grade________to participate in nursing services.

Noor-Ul-Iman School Name of School

____________________________________________ _______________________ Signature of Parent/Guardian Date

____________________________________________ Printed Name of Parent/Guardian

2017-2018 School Year

MIDDLESEX REGIONAL EDUCATIONAL SERVICES COMMISSION

DENTAL FORM

Date: ________________ Student Name: ___________________________ Grade: _______

Dear Parent/Guardian:

The school health policy recommends an annual dental examination by your family dentist for each

child enrolled in Noor-Ul-Iman School.

The form below is to be completed. If your child has had an examination in the last six (6) months,

please have the dentist complete this form.

Please return this form to the school nurse as soon as possible following your child’s dental

examination.

If there is any reason why you cannot have a dental examination done, please call me at (732) 329-

1800 ext. 207.

Thank you,

School Nurse

------------------------------------------------------------ ----------------------------------------------------------

I have examined __________________________________________ on __________________.

Student Name Date

___1. There is no need for corrective work at this time.

___2. Treatment has been completed.

___3. There is need for dental care at this time.

Has an appointment been scheduled? _____Yes _____No

___________________________________ ____________________

Dentist’s Signature Date

Printed Name and Address of Dentist: ______________________________

______________________________

______________________________

Telephone Number: ______________________________

NOOR-UL-IMAN SCHOOL

NOTIFICATION OF 6TH GRADE IMMUNIZATION REQUIREMENTS

Dear Parent/Guardian,

According to regulations set by the New Jersey Department of Health, children entering 6th

grade, who are 11 years of age, must receive the following immunizations:

1. Tdap – This vaccine may be delayed until 5 years after the last DTP/DTaP or Td dose.

Most likely, your child received a DTP/DTaP vaccine as a requirement for Kindergarten

and now due for Tdap.

2. Meningococcal – If this vaccine was given on or after the 10th birthday, it will be

acceptable.

Children who are 11 years old by the first day of school and are not in compliance with this

law, will not be allowed to start school until immunizations are received. Children who will

be turning 11 years old after commencing 6th grade, will have 2 weeks from their 11th birthday

to receive the Tdap and Meningococcal vaccines or will be excluded from school until these

immunizations are received.

Please have your physician complete these immunizations, verify immunizations given, with

dates, in the designated area below and return this form to school during orientation and no

later than the first day of school Wednesday, September 6, 2017.

Thank you in advance for your cooperation. Have a safe and healthy summer!

Sincerely,

Nurse’s Office

IMMUNIZATIONS GIVEN AND DATES:

Student’s Full Name:

Tdap Meningococcal

Doctor’s Signature and Date Office Stamp

Child’s Name (Last) (First) Gender Male Female

Date of Birth / /

Does Child Have Health Insurance?Yes No

If Yes, Name of Child's Health Insurance Carrier

Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number

Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number

I give my consent for my child’s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form.Signature/Date This form may be released to WIC.

Yes No

SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDERDate of Physical Examination: Results of physical examination normal? Yes No

Weight (must be takenwithin 30 days for WIC)Height (must be takenwithin 30 days for WIC)Head Circumference(if <2 Years)

Abnormalities Noted:

Blood Pressure(if >3 Years)

IMMUNIZATIONS Immunization Record Attached Date Next Immunization Due:

MEDICAL CONDITIONSChronic Medical Conditions/Related Surgeries• List medical conditions/ongoing surgical

concerns:

None Special Care PlanAttached

Comments

Medications/Treatments• List medications/treatments:

None Special Care PlanAttached

Comments

Limitations to Physical Activity• List limitations/special considerations:

None Special Care PlanAttached

Comments

Special Equipment Needs• List items necessary for daily activities

None Special Care PlanAttached

Comments

Allergies/Sensitivities• List allergies:

None Special Care PlanAttached

Comments

Special Diet/Vitamin & Mineral Supplements• List dietary specifications:

None Special Care PlanAttached

Comments

Behavioral Issues/Mental Health Diagnosis• List behavioral/mental health issues/concerns:

None Special Care PlanAttached

Comments

Emergency Plans• List emergency plan that might be needed and

the sign/symptoms to watch for:

None Special Care PlanAttached

Comments

PREVENTIVE HEALTH SCREENINGSType Screening Date Performed Record Value Type Screening Date Performed Note if Abnormal

Hgb/Hct HearingLead: Capillary Venous VisionTB (mm of Induration) DentalOther: DevelopmentalOther: Scoliosis

I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared toparticipate fully in all child care/school activities, including physical education and competitive contact sports, unless noted above.

Name of Health Care Provider (Print)

Signature/Date

Health Care Provider Stamp:

CH-14 SEP 08 Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider

SECTION I - TO BE COMPLETED BY PARENT(S)

UNIVERSALCHILD HEALTH RECORD

Nursing Office will indicate when new form is due, Forms for Athletes can be found on www.nuischool.org

CH-14 (Instructions)SEP 08

Instructions for Completing the Universal Child Health Record (CH-14)

Section 1 - ParentPlease have the parent/guardian complete the top section andsign the consent for the child care provider/school nurse todiscuss any information on this form with the health careprovider.

The WIC box needs to be checked only if this form is beingsent to the WIC office. WIC is a supplemental nutritionprogram for Women, Infants and Children that providesnutritious foods, nutrition counseling, health care referrals andbreast feeding support to income eligible families. For moreinformation about WIC in your area call 1-800-328-3838.

Section 2 - Health Care Provider1. Please enter the date of the physical exam that is being

used to complete the form. Note significant abnormalitiesespecially if the child needs treatment for that abnormality(e.g. creams for eczema; asthma medications forwheezing etc.)• Weight - Please note pounds vs. kilograms. If the

form is being used for WIC, the weight must havebeen taken within the last 30 days.

• Height - Please note inches vs. centimeters. If theform is being used for WIC, the height must havebeen taken within the last 30 days.

• Head Circumference - Only enter if the child is lessthan 2 years.

• Blood Pressure - Only enter if the child is 3 yearsor older.

2. Immunization - A copy of an immunization record maybe copied and attached. If you need a blank form onwhich to enter the immunization dates, you can request asupply of Personal Immunization Record (IMM-9) cardsfrom the New Jersey Department of Health and SeniorServices, Immunization Program at 609-588-7512.• The Immunization record must be attached for the

form to be valid.• “Date next immunization is due” is optional but helps

child care providers to assure that children in theircare are up-to-date with immunizations.

3. Medical Conditions - Please list any ongoing medicalconditions that might impact the child's health and wellbeing in the child care or school setting.

a. Note any significant medical conditions or majorsurgical history. If the child has a complexmedical condition, a special care plan should becompleted and attached for any of the medicalissue blocks that follow. A generic care plan(CH-15) can be downloaded atwww.state.nj.us/health/forms/ch-15.dot or pdf. Hardcopies of the CH-15 can be requested from theDivision of Family Health Services at 609-292-5666.

b. Medications - List any ongoing medications.Include any medications given at home if they mightimpact the child's health while in child care (seizure,cardiac or asthma medications, etc.). Short-termmedications such as antibiotics do not need to belisted on this form. Long-term antibiotics such asantibiotics for urinary tract infections or sickle cellprophylaxis should be included.

PRN Medications are medications given only asneeded and should have guidelines as to specificfactors that should trigger medication administration.

Please be specific about what over-the-counter(OTC) medications you recommend, and includeinformation for the parent and child care provider asto dosage, route, frequency, and possible sideeffects. Many child care providers may requireseparate permissions slips for prescription and OTCmedications.

c. Limitations to physical activity - Please be asspecific as possible and include dates of limitationas appropriate. Any limitation to field trips should benoted. Note any special considerations such asavoiding sun exposure or exposure to allergens.Potential severe reaction to insect stings should benoted. Special considerations such as back-onlysleeping for infants should be noted.

d. Special Equipment – Enter if the child wearsglasses, orthodontic devices, orthotics, or otherspecial equipment. Children with complexequipment needs should have a care plan.

e. Allergies/Sensitivities - Children with life-threatening allergies should have a special careplan. Severe allergic reactions to animals or foods(wheezing etc.) should be noted. Pediatric asthmaaction plans can be obtained from The PediatricAsthma Coalition of New Jersey at www.pacnj.orgor by phone at 908-687-9340.

f. Special Diets - Any special diet and/or supplementsthat are medically indicated should be included.Exclusive breastfeeding should be noted.

g. Behavioral/Mental Health issues – Please noteany significant behavioral problems or mental healthdiagnoses such as autism, breath holding, orADHD.

h. Emergency Plans - May require a special care planif interventions are complex. Be specific aboutsigns and symptoms to watch for. Use simplelanguage and avoid the use of complex medicalterms.

4. Screening - This section is required for school, WIC,Head Start, child care settings, and some otherprograms. This section can provide valuable data forpublic heath personnel to track children's health. Pleaseenter the date that the test was performed. Note if thetest was abnormal or place an "N" if it was normal.• For lead screening state if the blood sample was

capillary or venous and the value of the testperformed.

• For PPD enter millimeters of induration, and thedate listed should be the date read. If a chest x-raywas done, record results.

• Scoliosis screenings are done biennially in thepublic schools beginning at age 10.

This form may be used for clearance for sports orphysical education. As such, please check the box abovethe signature line and make any appropriate notations inthe Limitation to Physical Activities block.

5. Please sign and date the form with the date the form wascompleted (note the date of the exam, if different)• Print the health care provider's name.• Stamp with health care site's name, address and

phone number.

Continue daily control medicine(s) and ADD quick-relief medicine(s).

HEALTHY (Green Zone) ➠ Take daily control medicine(s). Some inhalers may be more effective with a “spacer” – use if directed.

You have all of these:• Breathing is good• No cough or wheeze• Sleep through

the night• Can work, exercise,

and play

And/or Peak flow above _______

You have any of these:• Cough• Mild wheeze• Tight chest• Coughing at night• Other: ___________

And/or Peak flow from______ to_____

Your asthma is getting worse fast:• Quick-relief medicine did

not help within 15-20 minutes• Breathing is hard or fast• Nose opens wide • Ribs show• Trouble walking and talking• Lips blue • Fingernails blue• Other: ________________

And/or Peak flow below ______

MEDICINE HOW MUCH to take and HOW OFTEN to take it� Advair® HFA � 45, � 115, � 230 ____________2 puffs twice a day� AerospanTM ______________________________� 1, � 2 puffs twice a day� Alvesco® � 80, � 160 ______________________� 1, � 2 puffs twice a day� Dulera® � 100, � 200 _____________________2 puffs twice a day� Flovent® � 44, � 110, � 220 _______________2 puffs twice a day� Qvar® � 40, � 80 ________________________� 1, � 2 puffs twice a day� Symbicort® � 80, � 160 ___________________� 1, � 2 puffs twice a day� Advair Diskus® � 100, � 250, � 500 _________1 inhalation twice a day� Asmanex® Twisthaler® � 110, � 220___________� 1, � 2 inhalations � once or � twice a day� Flovent® Diskus® � 50 � 100 � 250 _________1 inhalation twice a day� Pulmicort Flexhaler® � 90, � 180 ____________� 1, � 2 inhalations � once or � twice a day� Pulmicort Respules® (Budesonide) � 0.25, � 0.5, � 1.0__1 unit nebulized � once or � twice a day� Singulair® (Montelukast) � 4, � 5, � 10 mg _____1 tablet daily� Other� None

Remember to rinse your mouth after taking inhaled medicine.If exercise triggers your asthma, take_____________________  ____ puff(s) ____minutes before exercise.

TriggersCheck all itemsthat trigger patient’s asthma:

❏ Colds/flu❏ Exercise❏ Allergens

❍ Dust Mites, dust, stuffed animals, carpet

❍ Pollen - trees,grass, weeds

❍ Mold ❍ Pets - animal

dander❍ Pests - rodents,

cockroaches❏ Odors (Irritants)

❍ Cigarette smoke& second handsmoke

❍ Perfumes, cleaning products,scented products

❍ Smoke fromburning wood,inside or outside

❏ Weather❍ Sudden

temperaturechange

❍ Extreme weather- hot and cold

❍ Ozone alert days❏ Foods:❍

❍

❍

❏ Other:❍

❍

❍

Permission to Self-administer Medication:� This student is capable and has been instructed

in the proper method of self-administering of the non-nebulized inhaled medications named above in accordance with NJ Law.

� This student is not approved to self-medicate.

EMERGENCY (Red Zone) ➠

Asthma Treatment Plan – Student(This asthma action plan meets NJ Law N.J.S.A. 18A:40-12.8) (Physician’s Orders)

Name Date of Birth Effective Date

Doctor Parent/Guardian (if applicable) Emergency Contact

Phone Phone Phone

(Please Print)

MEDICINE HOW MUCH to take and HOW OFTEN to take it� Albuterol MDI (Pro-air® or Proventil® or Ventolin®) _2 puffs every 4 hours as needed� Xopenex®__________________________________2 puffs every 4 hours as needed� Albuterol � 1.25, � 2.5 mg ___________________1 unit nebulized every 4 hours as needed� Duoneb® __________________________________1 unit nebulized every 4 hours as needed� Xopenex® (Levalbuterol) � 0.31, � 0.63, � 1.25 mg _1 unit nebulized every 4 hours as needed� Combivent Respimat® ________________________1 inhalation 4 times a day� Increase the dose of, or add:� Other• If quick-relief medicine is needed more than 2 times aweek, except before exercise, then call your doctor.

Take these medicines NOW and CALL 911.Asthma can be a life-threatening illness. Do not wait!MEDICINE HOW MUCH to take and HOW OFTEN to take it� Albuterol MDI (Pro-air® or Proventil® or Ventolin®) ___4 puffs every 20 minutes� Xopenex® ___________________________________4 puffs every 20 minutes� Albuterol � 1.25, � 2.5 mg _____________________1 unit nebulized every 20 minutes� Duoneb® ____________________________________1 unit nebulized every 20 minutes� Xopenex® (Levalbuterol) � 0.31, � 0.63, � 1.25 mg ___1 unit nebulized every 20 minutes� Combivent Respimat® __________________________1 inhalation 4 times a day� Other

Make a copy for parent and for physician file, send original to school nurse or child care provider.

This asthma treatmentplan is meant to assist,not replace, the clinicaldecision-making required to meetindividual patient needs.

Disclaimers: The use of this Website/PACNJ Asthma Treatment Plan and its content is at your own risk. The content isprovided on an “as is” basis. The American Lung Association of the Mid-Atlantic (ALAM-A), the Pediatric/Adult Asthma Coalition of New Jersey and all affiliates disclaim all warranties, express or implied, statutory or otherwise, including but not limited to the implied warranties or merchantability, non-infringement of third parties’ rights, and fitness for a particular purpose.ALAM-A makes no representations or warranties about the accuracy, reliability, completeness, currency, or timeliness of thecontent. ALAM-Amakes no warranty, representation or guaranty that the information will be uninterrupted or error free or that anydefects can be corrected. In no event shall ALAM-A be liable for any damages (including, without limitation, incidental and consequential damages, personal injury/wrongful death, lost profits, or damages resulting from data or business interruption) resulting from the use or inability to use the content of this Asthma Treatment Plan whether based on warranty, contract, tort orany other legal theory, and whether or not ALAM-A is advised of the possibility of such damages. ALAM-A and its affiliates arenot liable for any claim, whatsoever, caused by your use or misuse of the Asthma Treatment Plan, nor of this website.

The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the American Lung Association in New Jersey. This publicationwas supported by a grant from the New Jersey Department of Health and Senior Services, with funds provided by the U.S. Centersfor Disease Control and Prevention under Cooperative Agreement 5U59EH000491-5. Its contents are solely the responsibility ofthe authors and do not necessarily represent the official views of the New Jersey Department of Health and Senior Services or theU.S. Centers for Disease Control and Prevention. Although this document has been funded wholly or in part by the United StatesEnvironmental Protection Agency under Agreement XA96296601-2 to the American Lung Association in New Jersey, it has not gonethrough the Agency’s publications review process and therefore, may not necessarily reflect the views of the Agency and no officialendorsement should be inferred. Information in this publication is not intended to diagnose health problems or take the place ofmedical advice. For asthma or any medical condition, seek medical advice from your child’s or your health care professional.

REVISED AUGUST 2014Permission to reproduce blank form • www.pacnj.org

PHYSICIAN/APN/PA SIGNATURE______________________________ DATE__________ Physician’s Orders

PARENT/GUARDIAN SIGNATURE______________________________

PHYSICIAN STAMP

If quick-relief medicine does not help within 15-20 minutes or has been used more than 2 times and symptoms persist, call your doctor or go to the emergency room.

Sponsored by

Asthma Treatment Plan – StudentParent InstructionsThe PACNJ Asthma Treatment Plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma.

1. Parents/Guardians: Before taking this form to your Health Care Provider, complete the top left section with:• Child’s name • Child’s doctor’s name & phone number • Parent/Guardian’s name• Child’s date of birth • An Emergency Contact person’s name & phone number & phone number

2. Your Health Care Provider will complete the following areas:• The effective date of this plan• The medicine information for the Healthy, Caution and Emergency sections• Your Health Care Provider will check the box next to the medication and check how much and how often to take it• Your Health Care Provider may check “OTHER” and:

v Write in asthma medications not listed on the form v Write in additional medications that will control your asthmav Write in generic medications in place of the name brand on the form

• Together you and your Health Care Provider will decide what asthma treatment is best for your child to follow

3. Parents/Guardians & Health Care Providers together will discuss and then complete the following areas:• Child’s peak flow range in the Healthy, Caution and Emergency sections on the left side of the form• Child’s asthma triggers on the right side of the form• Permission to Self-administer Medication section at the bottom of the form: Discuss your child’s ability to self-administer the

inhaled medications, check the appropriate box, and then both you and your Health Care Provider must sign and date the form

4. Parents/Guardians: After completing the form with your Health Care Provider:• Make copies of the Asthma Treatment Plan and give the signed original to your child’s school nurse or child care provider• Keep a copy easily available at home to help manage your child’s asthma• Give copies of the Asthma Treatment Plan to everyone who provides care for your child, for example: babysitters,

before/after school program staff, coaches, scout leaders

Sponsored byDisclaimers: The use of this Website/PACNJ Asthma Treatment Plan and its content is at your own risk. The content is provided on an “as is” basis. The American Lung Association of the Mid-Atlantic (ALAM-A), the Pediatric/AdultAsthma Coalition of New Jersey and all affiliates disclaim all warranties, express or implied, statutory or otherwise, including but not limited to the implied warranties or merchantability, non-infringement of third parties’ rights, andfitness for a particular purpose. ALAM-A makes no representations or warranties about the accuracy, reliability, completeness, currency, or timeliness of the content. ALAM-A makes no warranty, representation or guaranty that the in-formation will be uninterrupted or error free or that any defects can be corrected. In no event shall ALAM-A be liable for any damages (including, without limitation, incidental and consequential damages, personal injury/wrongfuldeath, lost profits, or damages resulting from data or business interruption) resulting from the use or inability to use the content of this Asthma Treatment Plan whether based on warranty, contract, tort or any other legal theory, andwhether or not ALAM-A is advised of the possibility of such damages. ALAM-A and its affiliates are not liable for any claim, whatsoever, caused by your use or misuse of the Asthma Treatment Plan, nor of this website.

The Pediatric/Adult Asthma Coalition of New Jersey, sponsored by the American Lung Association in New Jersey. This publication was supported by a grant from the New Jersey Department of Health and Senior Services, with fundsprovided by the U.S. Centers for Disease Control and Prevention under Cooperative Agreement 5U59EH000491-5. Its content are solely the responsibility of the authors and do not necessarily represent the official views of the NewJersey Department of Health and Senior Services or the U.S. Centers for Disease Control and Prevention. Although this document has been funded wholly or in part by the United States Environmental Protection Agency under AgreementXA96296601-2 to the American Lung Association in New Jersey, it has not gone through the Agency’s publications review process and therefore, may not necessarily reflect the views of the Agency and no official endorsement shouldbe inferred. Information in this publication is not intended to diagnose health problems or take the place of medical advice. For asthma or any medical condition, seek medical advice from your child’s or your health care professional.

PARENT AUTHORIZATION

I hereby give permission for my child to receive medication at school as prescribed in the Asthma Treatment Plan. Medication must be providedin its original prescription container properly labeled by a pharmacist or physician. I also give permission for the release and exchange ofinformation between the school nurse and my child’s health care provider concerning my child’s health and medications. In addition, I understand that this information will be shared with school staff on a need to know basis.

Parent/Guardian Signature Phone Date

FILL OUT THE SECTION BELOW ONLY IF YOUR HEALTH CARE PROVIDER CHECKED PERMISSION FOR YOUR CHILD TO SELF-ADMINISTER ASTHMA MEDICATION ON THE FRONT OF THIS FORM.RECOMMENDATIONS ARE EFFECTIVE FOR ONE (1) SCHOOL YEAR ONLY AND MUST BE RENEWED ANNUALLY

� I do request that my child be ALLOWED to carry the following medication ________________________________ for self-administrationin school pursuant to N.J.A.C:.6A:16-2.3. I give permission for my child to self-administer medication, as prescribed in this Asthma TreatmentPlan for the current school year as I consider him/her to be responsible and capable of transporting, storing and self-administration of themedication. Medication must be kept in its original prescription container. I understand that the school district, agents and its employeesshall incur no liability as a result of any condition or injury arising from the self-administration by the student of the medication prescribedon this form. I indemnify and hold harmless the School District, its agents and employees against any claims arising out of self-administrationor lack of administration of this medication by the student.

� I DO NOT request that my child self-administer his/her asthma medication.

Parent/Guardian Signature Phone Date

INDIVIDUAL EMERGENCY HEALTH PLAN FOR ANAPHYLAXIS for _____/_____ School Year (Anaphylaxis is a potentially life-threatening allergic reaction. Act quickly.) Place

Name:__________________________________ Date of Birth:___________ Picture Doctor:___________________________ Parent/Guardian:______________________ Here Phone:____________________________ Phone:________________________________ DELEGATES TRAINED IN THE USE OF EPINEPHRINE AUTO-INJECTORS: ______________________________________________ ______________________________________________ Asthmatic (Check if YES - Student has higher risk of a severe allergic reaction. Epinephrine should be given first (before asthma medications) in case of a reaction with any breathing symptoms. ALLERGEN(S):__________________________________________________________________________

Medications & Dosages: Child’s Weight:______lbs.

Epinephrine Auto-Injector, Jr. 0.15 mg intramuscularly prn anaphylaxis & call 911. May repeat once as indicated below if symptoms do not improve within 20 minutes of 1st dose or return of symptoms.

Epinephrine Auto-Injector 0.3 mg intramuscularly prn anaphylaxis & call 911. May repeat once as indicated below if symptoms do not improve within 20 minutes of 1st dose or return of symptoms.

Benadryl ____mg. po q 4-6 hrs prn allergic reaction. OR

Other antihistamine:_____________________ ___mg. po q___ hrs prn allergic reaction. CAUTION Epinephrine Epinephrine 2nd Dose Antihistamine No symptoms and suspected ingestion of allergen

No symptoms and known ingestion of allergen

Nose/Eyes: Hayfever-like symptoms: runny, itchy Nose, red eyes

Skin (1): Localized hives and/or localized itchy rash EMERGENCY Epinephrine Epinephrine 2nd Dose Antihistamine Mouth: Itching, tingling or swelling of lips, tongue or mouth Skin (2): Hives and/or itchy rash on more than one part of the

Body, swelling of face or extremities

Gut: Nausea, abdominal cramps, vomiting, diarrhea

Throat: Hacking cough, tightening of throat,hoarseness, Difficulty swallowing

Lung: Shortness of breath, wheezing, short, frequent, Shallow cough

Heart: Weak pulse, low blood pressure, fainting, dizzy, Pale, cyanotic (blueness)

Multiple: Symptoms from 2 or more of the above categories

For Minors Only: This student is capable and has been instructed in the proper method of self- administration of the Epinephrine Auto-injector in accordance with New Jersey Law.

This student is NOT approved to self-medicate.

This student MAY CARRY the Epinephrine Auto-injector.

This student MAY NOT CARRY the Epinephrine Auto-injector.

Noor-Ul-Iman School, Educational Services Commission of New Jersey and their employees/agents are not liable for any complications arising from the administration of the Epinephrine Auto-injector or other medication.

This student is my patient and I have ordered I authorize the administration of above for my child, the above treatment plan. to be followed by transportation to ____________ ___________________________________________ (or nearest) Hospital if Epinephrine is given. Physician Signature & Stamp (Below) Date

_______________________________________ Parent/Guardian Signature Date

FOR STUDENTS WITH SEVERE ALLERGIES