• 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.

    Youth Facility Information

     [None] Select a Date Delete the Date

    Recipient Information



    Location and Dosage Information


    Other Information

     [None] Select a Date Delete the Date

    (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."*




    Central Nervous System

    Cardiovascular System





    Suspected Cause





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




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Last updated February 24, 2021