Click here to reset the student specific fields on this form. Parent or Guardian information will not be affected by this RESET function.AUTHORIZATION FOR ANAPHYLAXIS ACTION PLAN PLEASE READ INFORMATION.

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How to use or fill out the VA Fairfax County Public Schools SS/SE-64 online

Filling out the VA Fairfax County Public Schools SS/SE-64 form online is a straightforward process aimed at ensuring that your child's anaphylaxis action plan is accurately recorded and followed. This guide provides step-by-step instructions on how to navigate each section of the form effectively.

Follow the steps to complete the VA Fairfax County Public Schools SS/SE-64 online.

  1. Click the 'Get Form' button to access the VA Fairfax County Public Schools SS/SE-64 form and open it for completion.
  2. In Part I, fill out the parent or guardian information, including the student’s name, date of birth, school name, school year, and grade. Ensure all details are accurately entered to avoid delays.
  3. Provide your authorization by signing the designated area under the parent or guardian signature section. This confirms that you allow Fairfax County Public Schools personnel to administer epinephrine as per the health care provider's instructions.
  4. Include your daytime telephone number and the date of signing the form. This information allows for direct contact if there are any questions regarding the authorization.
  5. In Part II, have the health care provider complete their section. They will provide specific details regarding the administration of epinephrine, including allergen information and dosage instructions.
  6. Once the health care provider has filled out their details, ensure they sign and date the form. Their signature is crucial for the validity of the authorization.
  7. If the student is permitted to carry the epinephrine, the student's signature and parent or guardian signature are required in this section, confirming their understanding of the responsibilities involved.
  8. For Part III, ensure that the principal or their designee completes their section. This includes verifying that Part I and Part II are complete and includes the necessary signatures. Date the section to confirm the review.
  9. Once all parts of the form are completed and reviewed, you can save your changes. Additionally, you have the option to download, print, or share the form as needed.

Complete the VA Fairfax County Public Schools SS/SE-64 form online today to ensure your child’s safety and preparedness in managing anaphylaxis.

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What is the route of epinephrine?

This medicine is injected under the skin or into the muscle of your outer thigh only. Do not inject this medicine into a vein, into the muscle of your buttocks, or into your fingers, toes, hands, or feet. To do so, may increase the chance of having serious side effects.

For two decades, epinephrine injections have been recommended to be delivered intramuscularly (IM) into the mid antero-ventral thigh [7].

Adverse Effects The more common side effects include tachycardia, hypertension, headache, anxiety, apprehension, palpitations, diaphoresis, nausea, vomiting, weakness, and tremors. Careful monitoring of vital signs is crucial, especially in patients with polypharmacy.

Epinephrine injection comes as a prefilled automatic injection device containing a solution (liquid) and in vials to inject subcutaneously (under the skin) or intramuscularly (into the muscle). It is usually injected as needed at the first sign of a serious allergic reaction.

An infusion of IV epinephrine provides greater control. If the patient has an adverse event, then the epinephrine can be stopped or down-titrated. Thus, using an epinephrine infusion may actually encourage the use of epinephrine overall – because you don't have to make a commitment to give the drug for ~30 minutes.

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