Click here to reset the student specific fields on this form. Parent or Guardian information will not be affected by this RESET function. EPINEPHRINE AUTHORIZATION PLEASE READ INFORMATION AND PROCEDURES ON REVERSE SIDE PART I PARENT OR GUARDIAN TO COMPLETE I hereby authorize Fairfax County Public Schools FCPS Fairfax County Health Department FCHD and School Age Child Care SACC personnel to administer epinephrine injection s as directed by the phy.
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How to 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 an important step in ensuring that the appropriate medication management is in place for students who may require epinephrine. This guide provides clear instructions on how to complete the form accurately.
Follow the steps to complete the form online efficiently.
- Use the ‘Get Form’ button to access the SS/SE-64 form and open it in the online editor.
- Begin with Part I, where the parent or guardian must provide information about the student. Fill in the student's name, date of birth, school name, school year, and grade.
- In this section, the parent or guardian must authorize the administration of epinephrine by signing and dating the relevant field. Include a daytime telephone number for contact.
- Proceed to Part II, which must be completed by a licensed prescriber. Ensure that the prescriber’s name, date, and contact number are included, alongside their signature.
- Detail the specific allergens and the route of exposure, choosing from the provided options. Clearly state the amount of epinephrine to be administered and outline any necessary repeated doses.
- Complete the effectiveness dates for the prescription, making sure to include the range for the current school year.
- Ensure that both the parent or guardian and licensed prescriber have signed the form. Check that all parts are completed as necessary. Note the labeling requirements for the medication.
- Finally, confirm everything is accurate, make any adjustments if needed, and save your changes. You may choose to download, print, or share the completed SS/SE-64 form with the respective school authorities.
Complete the VA Fairfax County Public Schools SS/SE-64 form online to ensure timely medical support for your student.
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Is epinephrine ever given IV?
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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