Documentation Required Annually
To be sent to PCOE
Epinephrine Standing Order Protocol and Certification Form
List of schools, if more than one, within the district that will house Epinephrine Auto Injectors
Epinephrine Administration Training Log Sign-In Sheets
Required Training Documentation
To be kept at district level
Anaphylaxis Training Protocol
Anaphylaxis Treatment Procedures
Notification of Volunteer Agreement for Training in Administration of Epinephrine Auto Injector
Epinephrine Indemnity Acknowledgment
Anaphylaxis Online Information
Epinephrine Administration Training Log Sign-In Sheets
Required Documentation for Acquisition and Disposition
Emergency Response Report – Management of Anaphylactic Reaction
Send completed report to PCOE Epinephrine Liaison for the County Health Officer’s review
Acquisition and Disposition of Epi-Pen, District Level
Acquisition and Disposition of Epi-Pen, Site Level