Texas School Health Program

Texas School Health Program

Required Reporting Forms

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Email
Phone
512-776-7279
Fax
512-776-7555
Mailing Address

Texas School Health Program
PO Box 149347
MC 1945
Austin, TX 78714-9347
United States

Physical Address

1100 West 49th Street
Austin, TX 78756
United States

Youth Facilities - Required Reporting of Unassigned Administered Epinephrine Auto-Injectors to DSHS

Youth facilities must report the administration of unassigned epinephrine auto-injectors. This requirement is in the Texas Health and Safety Code, §773.0145. 

25 Texas Administrative Code, Part 1, Chapter 40, Subchapter C, Section 40.23 defines youth facilities as: 

  • Child-care facility
  • Day camp or youth camp
  • Youth center
  • Small employer-based day-care facility
  • Temporary shelter day-care facility
  • Listed family homes
  • Any other private or public entity that would benefit from the possession and administration of epinephrine auto-injectors, that provide services for youth under the age of eighteen

No later than 10 business days after the date an unassigned epinephrine auto-injection is administered, youth facilities must submit a report in accordance with the 25 Texas Administrative Code, Part 1, Chapter 40, Subchapter C, Section 40.27. The report must be submitted to the: 

  • Owner of the facility,
  • Prescribing physician, and
  • Commissioner of the Department of State Health Services (DSHS).

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

Please fill out the entire form and provide detailed information.

All fields with an asterisk (*) must be completed.

Youth Facility Information

Recipient Information
Person who received the epinephrine auto-injector injection:

Location and Dosage Information
(Examples: playground, kitchen, office, etc. You do not need to include mailing address.)
(1 dose = 1 epinephrine auto-injector)
Type of dose administered:

Other Information
(Examples: volunteer, associate, receptionist, manager, etc.)
Did the person who received the epinephrine auto-injector injection have a known history of anaphylaxis or allergies requiring epinephrine auto-injectors?
Did the person who received the epinephrine auto-injector injection have a known history of asthma?
Was the youth facility's unassigned epinephrine auto-injector utilized?
Notification of medication administration was submitted to the following: Please mark all that apply.
(Examples: 9-1-1 was called, emailed prescribing physician that unassigned medication was used, etc.)
After the medication was administered, the recipient:

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
Please list signs or symptoms not listed above, if applicable:

Suspected Cause
Please indicate the suspected cause or trigger of the anaphylaxis:
(Examples: Eggs, Milk, Peanuts, Tree nuts, Fish, Shellfish, Wheat, Soy, Sesame, etc.

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