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

    If you are a youth facility, there are reporting rules. The rules apply to unassigned epinephrine auto-injectors. The rule says you must report the administration of unassigned epinephrine auto-injectors. This requirement is in the Texas Health and Safety Code, §773.0145.

    Your youth facility must report no later than the 10th business day 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).

    NOTE: Texas Administrative Code, Chapter 40, Subchapter C Epinephrine Auto-Injectors Youth Facilities refers to the following:

    • 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 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."*

    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