• Required Reporting of Unassigned Administered Epinephrine Auto-Injectors to DSHS from Certain Entities

    If you are an entity or venue that voluntarily adopts an unassigned epinephrine auto-injector policy there are reporting rules. The rules apply to certain entities and venues. This requirement is in the Texas Health and Safety Code, §773.0145 and Texas Administrative Code, Subchapter B, Chapter 40, Section 40.11-40.18.

    Your entity or venue must report no later than the 10th business day after the date an employee or volunteer administers an unassigned epinephrine auto-injector. You must submit the report to the:

    • prescribing physician, and
    • commissioner of the Department of State Health Services (DSHS).

    NOTE: Texas Administrative Code, Chapter 40, Subchapter B Epinephrine Auto-Injectors Certain Entities refers to the following:

    • amusement parks
    • restaurants
    • sports venues

    Submission of this electronic form meets the reporting requirement for DSHS. Be sure to report complete and accurate information.

    Please fill out the entire form and provide detailed information.
    All fields with an asterisk (*) must be completed.

    Certain Entity/Venue Information

     

    Please spell out the name of the venue or entity.
    Do not use an abbreviation.

       [None] Select a Date Delete the Date

    Recipient Information

     

     

     

    Location and Dosage Information

     

    (You do not need to include mailing address.)  
     


    (1 dose = 1 epinephrine auto-injector)

     

    Other Information

     

    (Examples: volunteer, associate, receptionist, manager, etc.)
     

     

     

                                                             

     

                                                                             

    Symptom Information

     

    A person experiencing anaphylaxis may have many signs and symptoms. Please select the symptoms that the individual who received the auto-injector injection was exhibiting.

    Please mark all that apply.
    If no symptoms for a particular group occurred, choose "N/A."*

    Respiratory

    Skin

    Gastrointestinal

                                                                                

    Central Nervous System

                                                                            

    Cardiovascular System

    Other

     

     

    Suspected Cause

     

     

     

     

    Please remember to promptly replace your used epinephrine auto-injector.

     

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Last updated February 24, 2021