Texas School Health Program

Texas School Health Program

Required Reporting Forms

Contact Us

Contact Us

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

Schools - Required Reporting of Unassigned Administered Epinephrine Auto-Injectors to DSHS

School districts, open-enrollment charter schools, private schools, and institutions of higher education must report the administration of unassigned epinephrine auto-injectors. This requirement is in the Texas Education Code, Section 38.209 and Section 51.883.

Texas Education Code, Section 61.003(8) and (15) defines institution of higher education as a:

  • Technical institute
  • Junior college or community college
  • College or university
  • Medical or dental school
  • Public state college
  • Agency of higher education

No later than 10 business days after the date of an unassigned epinephrine auto-injection is administered, school campuses and institutions of higher education must submit a report in accordance with the 25 Texas Administrative Code, Part 1, Chapter 40, Subchapter E, Section 40.68 and 25 Texas Administrative Code, Part 1, Chapter 40, Subchapter A, Section 40.7.

School districts, open-enrollment charter schools, and private schools must report to the:

  • School district
  • Charter holder if the school is an open-enrollment charter school
  • Governing body of the school if the school is a private school
  • Prescribing physician
  • Commissioner of the Department of State Health Services (DSHS)

Institutions of higher education must report to the:

  • Prescribing physician
  • Commissioner of DSHS

Private or independent institutions of higher education are not required to submit reports. DSHS encourages all institutions of higher education to report the use of epinephrine auto-injectors.

Note: 25 Texas Administrative Code, Part 1, Chapter 40, Subchapter E, Section 40.65(e) requires schools to notify local emergency medical services when an individual is suspected of experiencing anaphylaxis and when an epinephrine auto-injector is administered. For information on this requirement, please read EMS Evaluation After Administering Epinephrine in Schools.

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.

 

School Information
Select if you are reporting for a K-12 school or an institution of higher education:
 (Select N/A if this report is for an institution of higher education.) 
 (Type N/A if this report is for a school district, open-enrollment charter school, or private school.)

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

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)
Type of dosage administered:

Other Information
(Examples: 6th grade teacher, school librarian, basketball coach, school volunteer, 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 school'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.)
CAPTCHA
4 + 0 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.