Required Reporting of Unassigned Administered Epinephrine Auto-Injectors to DSHS from Certain Entities

If you are an entity or venue that voluntarily adopts an unassigned epinephrine auto-injector policy, there are reporting rules. The rules apply to certain entities and venues. This requirement is in the Texas Health and Safety Code, §773.0145 and Texas Administrative Code, Subchapter B, Chapter 40, Section 40.11-40.18.

Your entity or venue must report no later than the 10th business day after the date an employee or volunteer administers an unassigned epinephrine auto-injector. You must submit the report to both the:

  • prescribing physician
  • commissioner of the Department of State Health Services (DSHS)

NOTE: Texas Administrative Code, Chapter 40, Subchapter B Epinephrine Auto-Injectors Certain Entities refers to the following:

  • amusement parks
  • restaurants
  • sports venues

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/Venue Information
Please spell out the name of the venue or entity.
Do not use an abbreviation.

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

Location and Dosage Information
(You do not need to include mailing address.)  
(1 dose = 1 epinephrine auto-injector)
Type of dosage administered:

Other Information
(Examples: volunteer, associate, receptionist, manager, etc.)
Did the person who received the epinephrine auto-injector injection have a known history of anaphylaxis or allergies requiring epinephrine auto-injectors?
Was the entity or venue’s unassigned epinephrine auto-injector used?
Was the individual who received the epinephrine auto-injector injection transported to local emergency medical services?

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:
Please remember to promptly replace your used epinephrine auto-injector.
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Texas School Health Program

Texas School Health Program

Required Reporting Forms

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