Required Reporting of Epinephrine Auto-Injectors to DSHS

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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.

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Last updated July 3, 2017

School Information
Name of the school district, open-enrollment charter school, or private school:*
Email:*
ESC region for your school district, open-enrollment charter school, or private school:*
Recipient Information
Person who received the epinephrine auto-injector injection:*	Student School Personnel or School Volunteer Visitor
Age of person who received the epinephrine auto-injector injection:*
Location and Dosage Information
Physical location of where the injection was administered:* (Examples: cafeteria, classroom, school bus, hallway, football field, etc. You do not need to include mailing address.)
Number of doses administered:* (1 dose = 1 epinephrine auto-injector)
Type of dosage administered:*	Child dose Adult dose
Other Information
Date administered:*	[None]
Title of the person who administered the injection:* (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?* Yes No Unknown
Was the school's 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
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	Wheezing or coughing Trouble breathing or shortness of breath Tightness in throat or chest Tingling or numbing sensation N/A (no respiratory symptoms)
Skin	Rash Hives Itchiness N/A (no skin symptoms)
Gastrointestinal	Cramps Diarrhea Vomiting N/A (no gastrointestinal symptoms)
Central Nervous System	Headache Swelling of lips, tongue, or throat Loss of consciousness Anxiety 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: