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Contact Us
Texas School Health Program
PO Box 149347, MC 1945
Austin, TX 78714-9347
1100 West 49th Street
Austin, Texas 78756
Phone: 512-776-7279
Fax: 512-776-7555

Email comments or questions to SchoolHealth@dshs.texas.gov

Required Reporting of Administered Epinephrine
Auto-Injectors to DSHS

If you are a school district, open-enrollment charter school, private school, or institution of higher education, 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 Education Code, §38.209 and §51.883.

You must report no later than the 10th business day after the date of an unassigned epinephrine auto-injection is administered in accordance with the Texas Administrative Code, Title 25, Part 1, Chapter 37, Section 37.608 and Texas Administrative Code, Title 25, Part 1, Chapter 40, 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

NOTE: Texas Education Code, Chapter 61, §61.003 defines institution of higher education as a:

Technical Institute,
Junior College or Community College,
College or University,
Medical or Dental School,
Public State College, and an
Agency of Higher Education.

We do not require private institutions of higher education to submit reports at this time. DSHS encourages all institutions of higher education to report the use of epinephrine auto-injectors.

Please fill out the entire form and provide detailed information.
All fields with an asterisk (*) must be completed.

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Last updated February 5, 2021

School Information
Select if you are reporting for a K-12 school or an institution of higher education:*	K-12 School Institution of Higher Education
Name of the institution of higher education, school district, open-enrollment charter school, or private school:*
Email address of person completing this form:*
Education Service Center region for your school district, open-enrollment charter school, or private school: (Enter N/A if this report is for an institution of higher education.)*
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 where you administered the injection:* (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
Texas Administrative Code §37.605(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 (PDF). Were local emergency medical services (EMS) notified about the individual who received the injection from the epinephrine auto-injector?* (Examples: 9-1-1 was called, individual was transported by local EMS to hospital, etc.) 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 occurred, choose "N/A."*
Respiratory	Wheezing or coughing Trouble breathing or shortness of breath Tightness in throat or chest 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 Tingling or numbing sensation (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:

Required Reporting of Administered Epinephrine Auto-Injectors to DSHS

School Information

Recipient Information

Location and Dosage Information

Other Information

Symptom Information

Suspected Cause

Required Reporting of Administered Epinephrine
Auto-Injectors to DSHS