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Reaction THOROUGHLY REVIEW ENCLOS ED AUTO-INJ ECTAB LE EPINEPHRINE ADMINISTRATION INFORMATION BEFORE COMPLETING SECTION 1 - For Completion by Parent(s) / Guardian(s) Student s Name: 1. 2. School: School Year: Grade: Do you want the School Nurse / School Health Supervisor to instruct/review instructions in auto-injectable epinephrine administration with your child? Yes No Is your child capable of self-administering the auto-injectable epinephrine, if needed? Yes No SECTION.

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