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Texas School Health Program
PO Box 149347, MC 1945
Austin, TX 78714-9347
1100 West 49th Street
Austin, Texas 78756
Phone: 512-776-7279
Fax: 512-776-7555

Email comments or questions to SchoolHealth@dshs.texas.gov

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

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

Youth facilities must report no later than 10 business days after the date an unassigned epinephrine auto-injection is administered in accordance with the Texas Administrative Code, Title 25, Part 1, Chapter 40, Section 40.21-40.28. The report must be submitted to the:

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

Texas Administrative Code, Title 25 , 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

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.

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Last updated February 24, 2021

Youth Facility Information
Name of youth facility: *
Date Reported: *	[None]
Email address of person completing this form: *
Recipient Information
Person who received the epinephrine auto-injector injection: *	Student or Youth Personnel or Staff Member Recipient at temporary shelter day-care facility or listed family homes Volunteer Visitor Other
Age of person who received the epinephrine auto-injector injection: *
Location and Dosage Information
On site location where you administered the injection: * (Examples: playground, kitchen, office. You do not need to include mailing address.)
Number of doses administered (1 dose = 1 epinephrine auto-injector): *
Type of dose administered: *	Child dose Adult dose
Other Information
Date administered: *	[None]
Title of the person who administered the injection:* (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?* Yes No Unknown
Was the youth facilities unassigned epinephrine auto-injector utilized?* Yes No
Was the individual who received the epinephrine auto-injector injection transported to local emergency medical services?* Yes No
After the medication was administered the child: * Returned to youth activity or location Was picked up by a parent or guardian and taken home Was picked up by a parent or guardian and taken to a healthcare provider Was picked up by a parent or guardian, but unknown if medical care was obtained Was taken by EMS to the Emergency Room Other (Unknown)
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	Wheezing or coughing Trouble breathing or shortness of breath N/A (no respiratory symptoms)
Skin	Rash Hives Itchiness Swelling of lips, tongue, or throat N/A (no skin symptoms)
Gastrointestinal	Cramps Diarrhea Vomiting N/A (no gastrointestinal symptoms)
Central Nervous System	Headache Loss of consciousness Anxiety Tingling or numbing sensation N/A (no CNS symptoms)
Cardiovascular System	Dizzy or lightheaded Rapid pulse Low blood pressure N/A (no cardiovascular symptoms)
Other	Please list signs or symptoms not listed above, if applicable:
Suspected Cause
Please indicate the suspected cause or trigger of the anaphylaxis:*	Food Latex Insect sting or bite Medication Unknown Other
If you selected "Other" for the suspected cause question above, please explain:
Please remember to promptly replace your used epinephrine auto-injector.

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

Youth Facility Information

Recipient Information

Location and Dosage Information

Other Information

Symptom Information

Suspected Cause