• Required Reporting of Administered Epinephrine Auto-Injectors to DSHS

    Texas Education Code, Section 38.209 requires a school district, open-enrollment charter school, or private school who adopts an epinephrine auto-injector policy under Section 38.208 to report the use of an epinephrine auto-injector within 10 business days to the school district, charter holder if the school is an open-enrollment charter school, or the governing body of the school if the school is a private school, the physician or other person who prescribed the epinephrine auto-injector, the commissioner of education, and the commissioner of state health services. Submission of this electronic form with complete and accurate information meets the requirement of reporting to the commissioner of health (DSHS).

    • Please fill out the entire form and provide detailed information.
    • Please spell out school district name rather than using an abbreviation.
    • Please remember to also report this information to your school district, charter holder, or governing body, to the physician or other person who prescribed the epinephrine auto-injector, and to the commissioner of education (TEA).


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


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

    School Information

    Recipient Information

                       

    Location and Dosage Information


    (Examples: cafeteria, classroom, school bus, hallway, football field, etc. You do not need to include mailing address.)


    (1 dose = 1 epinephrine auto-injector)

                      
    Other Information

     [None] Select a Date Delete the Date


    (Examples: 6th grade teacher, school librarian, basketball coach, school volunteer, 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 occured, choose "N/A."*

    Respiratory

                                  

    Skin

                                  

    Gastrointestinal

                                  

    Central Nervous System

                              

    Cardiovascular System

                                  

    Other

     

    Suspected Cause

                               

     
     


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Last updated July 3, 2017