8 allergy corrected lamp 09redone 1.27.10
Part 2: Life-Threatening Allergy Management Plan (LAMP)
To Be Completed By Health Care Provider Valid for Current School Year ________________
Name: ___________________________________ DOB: ___________________
No *High risk for severe reaction □yes □ no
□ Asthma Action Plan
It is medically necessary for student to carry epinephrine during school hours
Yes No Signs of an Allergic Reaction Include:
Itching and swelling of the lips tongue or mouth
Itching and or a sense of tightness in the throat, hoarseness and hacking cough
Hives, itchy rash and/or swelling about the face or extremities
Nausea, abdominal cramps, vomiting, and/or diarrhea
Shortness of breath, repetitive cough and/or wheezing
*the severity of symptoms can quickly change. All the above symptoms can potentially progress to a life-threatening situation* Action for a Minor Reaction:
1. If ingestion is suspected and/or symptom(s) are: minor itching “and/or” mild hives to skin give
Liquid Benadryl (or generic dephenhydramine) Dose:______________________
by mouth now and every 4-6 hours as needed.
2. Call Mother at _____________________ Father at _________________ or emergency contact.
3. Call Dr. _____________ at ___________________ to make physician aware of child’s reaction.
If condition worsens or does not improve within 10 minutes follow steps for MAJOR Reaction below:
Action for a Major Reaction:
1. If symptom(s) are large amount of hives, throat swelling, cough, difficulty breathing, wheezing,
vomiting, diarrhea or if symptoms progress after Benadryl is given, give:
-Epinephrine: inject intramuscularly:
Epipen® Epipen® Jr Twinject ™ 0.3mg Twinject ™ 0.15mg
: dose: ____________ every 4-6 hours as needed (if able to tolerate liquids)
-Albuterol /or quick relief inhaler:
2 puffs with spacer now (IF asthmatic)
Give above now then call
2. Call RESCUE SQUAD 911 ASK FOR ADVANCED LIFE SUPPORT
3. Repeat dose of Epinephrine if no improvement in 5-10 minutes
4. Call Mother at _____________________ Father at _________________ or emergency contact.
5. Call Dr. _____________ at _______________ to make physician aware of child’s reaction. ________________________ _________ _________________________ _________
Print MD Name: ___________________________________
Part 3: Life-Threatening Allergy Management Plan (LAMP)
Permission to Carry and/or Self-Administer Epinephrine (if appropriate)
Name: _________________________________ DOB: __________________________
I, as the Healthcare Provider, certify that this child has a medical history of severe allergic reactions has been
trained in the use of the prescribed medication(s) and is judged to be capable of carrying and self-administering this medication(s). The nurse or the appropriate school staff should be notified anytime the medication/injector is used. This child understands the hazards of sharing medications with others and has agreed to refrain from this practice.
_________________________________ ________________________________ ____________ Healthcare Provider Signature Print Healthcare Provider name Date
In accordance with the Code of Virginia Section 22.1-274, I agree to the following: I will not hold the school board or any of its employees liable for any negative outcome resulting from the
self-administration of said emergency medication by the student.
I understand that the school, after consultation with the parent(s) may impose reasonable limitations or
restrictions upon a student’s possession and/or self-administration of said emergency medication relative to the age and maturity of the student or other relevant consideration.
I understand that the school may withdraw permission to possess and self-administer the said emergency
medication at any point during the school year if it is determined the student has abused the privilege of possession and self-administration or that the student is not safely and effectively self-administering the medication.
GZI Real Estate Investment Trust (a Hong Kong collective investment scheme authorised under section 104 of the Securities and Futures Ordinance (Chapter 571 of the Laws of Hong Kong)) (Stock Code: 405) Managed by GZI REIT Asset Management Limited NOTICE OF ANNUAL GENERAL MEETING NOTICE IS HEREBY GIVEN that an Annual General Meeting of unitholders of GZI Real Estate Investment
PRODUCT SAFETY DATA SHEET INSECTICIDE 1. Identification of the substance/preparation and company PRODUCT NAME: Insecticide PRODUCT USE: For the control of crawling and flying insects. SUPPLIER: Eastby Services Limited t/a Alltec Network Butts Farm, Fowlmere, Nr Royston, Herts EMERGENCY TEL No. 01763-208222 01763-208906 2. Composition/inf