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

Certain Entity – Required Reporting of Unassigned Administered Epinephrine to DSHS

Certain entities that voluntarily adopt an unassigned epinephrine policy must report the administration of unassigned epinephrine. This requirement is in the 25 Texas Administrative Code, Section 40.17.

No later than the 10th business day after the date unassigned epinephrine is administered, your entity must submit a report in accordance with the 25 Texas Administrative Code, Sections 40.17. The report must be submitted to the:

  • Prescribing physician and
  • Commissioner of the Department of State Health Services (DSHS).

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.

Certain Entity Information

Please spell out the name of the entity.
Do not use an abbreviation.

Recipient Information
Person who received the epinephrine:

Location and Dosage Information
(Examples: kitchen, bathroom, hallway, football field, etc. You do not need to include mailing address.)
Administered by auto-injector or nasal spray:
(1 dose = 1 epinephrine auto-injector; 1 dose = 1 nasal spray) 
Type of dosage administered:

Other Information
(Examples: volunteer, associate, receptionist, manager, etc.)
Did the person who received the epinephrine have a known history of anaphylaxis or allergies requiring epinephrine?
Did the person who received the epinephrine have a known history of asthma?*
Was the entity's unassigned epinephrine used?
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 epinephrine 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:

Please remember to promptly replace your used epinephrine.

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