UCA 26-41-104 Utah Department of Health STUDENT INFORMATION Asthma: Yes (if yes, high risk for severe reaction, please also complete IHP101.1 form) No Student: DOB: School: Parent: Phone: Email: Physician: Phone: Fax or email: School Nurse: School Phone: Fax or email: Grade: EXTREMELY REACTIVE TO THE FOLLOWING: Allergen(s): If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms. If checked, give epinephrine immediately if the allergen was.
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How to fill out the UT UDOH IHP104.1 online
The UT UDOH IHP104.1 form is essential for managing allergy and anaphylaxis information for students. This guide provides clear, step-by-step instructions for completing this form online, ensuring that users can easily navigate the process.
Follow the steps to fill out the UT UDOH IHP104.1 online effectively.
- Press the ‘Get Form’ button to access the document and open it in your browser.
- Begin by filling out the student information section. Enter the student's name, date of birth, school, and the parent or guardian's contact details including phone and email.
- Indicate whether the student has asthma by selecting 'Yes' or 'No'. If 'Yes', remember to complete the IHP101.1 form for high-risk individuals.
- List any known allergens the student is extremely reactive to, checking the appropriate boxes for allergens such as peanuts, tree nuts, or dairy.
- Complete the actions for mild to moderate allergic reaction by outlining the steps to follow based on the symptoms present.
- Detail the actions to take in the event of a severe allergic reaction. This includes injecting epinephrine immediately and contacting emergency services.
- The healthcare provider should complete their section with their name, signature, and date. They must also indicate the student's self-carry capability.
- The parent or guardian must complete their section, providing authorization and contact information, including their signature.
- Ensure the school nurse or principal's designee signs the form, confirming that the medication is appropriately labeled and that need-to-know staff have received necessary information.
- Once all sections are completed, save any changes made, then download, print, or share the form as required.
Complete the UT UDOH IHP104.1 form online today to ensure effective allergy management for your student.
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