School/Daycare Food Allergy Action Plan

NOT COMPLETE—DO NOT USE UNTIL VERIFIED (Display this banner if any critical field is missing: [Current Weight with date obtained], [Epinephrine route, dose, and device/brand], [Emergency contact phone numbers], and [Parent/Guardian and Clinician authorization signatures]. Do not infer or auto-populate critical fields.)

Child Name: [Child name]

Date of Birth / Age: [DOB / Age]

Current Weight: [Weight with units] (date obtained): [Date] (Required for dosing verification; do not estimate)

Classroom/Teacher: [Classroom / Teacher]

School/Daycare: [School or Daycare name]

Photo: [Photo placeholder]

Plan Date: [Plan date]    Effective Through: [Expiration date]

Allergy Profile

• Confirmed Allergens: [List each allergen explicitly]
• Prior Anaphylaxis: [Yes / No] (If Yes: [Date and setting])
• Asthma: [Yes / No]
• Severe Allergy Alert: [checkbox] Give epinephrine even for mild symptoms after exposure to: [Specified allergen(s)] (Only display if clinician selects this alert)

EMERGENCY ACTION — START HERE

Symptom Recognition

Only a few symptoms may be present. Severity can change quickly. If in doubt, give epinephrine.

• Mouth/Throat: itching, swelling, tightness, trouble swallowing
• Skin: hives, flushing, swelling
• GI: vomiting, diarrhea, cramping
• Lungs: cough, wheeze, shortness of breath
• Circulation/Neuro: pale/blue color, weak pulse, dizziness, fainting

Emergency Response

(Use the pathway that matches current symptoms. Switch to the Severe Reaction pathway immediately if any severe symptom appears or symptoms involve more than one body system.)

Severe Reaction / Anaphylaxis Trigger criteria: Any severe symptom (breathing difficulty, throat tightness, fainting, weak pulse, cyanosis) OR symptoms in more than one body system after suspected exposure.

1. Give epinephrine immediately. Note time given: _________
2. Call 911. State: "anaphylaxis." Request EMS with epinephrine capability.
3. Stay with child. Call parent/guardian. Monitor breathing and responsiveness continuously.
4. Position: Keep child lying down; side position if vomiting or having breathing difficulty. Do not allow food or drink.
5. Second dose: If no improvement or symptoms worsen after [Interval in minutes] minutes, give second epinephrine dose if available. Note time given: _________
6. Adjunct medications: May give antihistamine and/or bronchodilator after epinephrine only as adjuncts, never instead of epinephrine.

Mild Reaction Examples: Mild, isolated symptoms in a single body system (e.g., a few hives or mild mouth itch) without breathing, throat, or circulatory symptoms.

1. Monitor closely. Stay with child; check symptoms frequently.
2. Give antihistamine only if prescribed and symptoms remain mild and isolated.
3. Escalate immediately to Severe Reaction pathway if symptoms progress, involve more than one body system, or any severe symptom appears.
4. Notify parent/guardian.

Medications

Epinephrine (Clinician must explicitly select route, dose, and device—do not infer from weight alone)

• Route: [IM auto-injector / intranasal]
• Dose: [Epinephrine dose in mg or device strength]
• Device/Brand: [Device/brand name]
• Location(s) Stored: [Exact storage locations on site]
• Second Dose Available: [Yes / No]   Location: [Location of second dose]

Antihistamine (Include only if prescribed)

• Medication: [Medication name and formulation]
• Dose: [Dose with units and route]
• Criteria: [When to administer for mild reaction]

Bronchodilator (Include only if prescribed)

• Medication: [Medication name and device]
• Dose: [Dose and frequency]
• Criteria: [When to administer, e.g., after epinephrine for persistent wheeze]

Antihistamines and inhalers are NOT substitutes for epinephrine in anaphylaxis.

Daily Management

• [checkbox] No food sharing. Use only foods verified as safe per this plan.
• [checkbox] Handwashing with soap and water before and after meals. (Sanitizers do not remove allergens.)
• [checkbox] Clean eating surfaces before and after eating.
• [checkbox] Safe snack arrangements: [Approved snacks/alternatives/storage details]
• [checkbox] Field trips and transportation: Epinephrine and medications travel with trained adult. [Specific arrangements]

Contacts

• Parent/Guardian: [Name] — [Primary phone] ; [Alternate phone]
• Emergency Contact: [Name] — [Phone]
• Clinician: [Name, credentials] — [Phone]

Authorizations

Parent/Guardian Authorization

• [checkbox] Consent for administration of medications per this plan
• [checkbox] Consent to activate 911/EMS for suspected anaphylaxis
• [checkbox] Consent to share this plan with relevant school/daycare staff

Parent/Guardian Signature: _________________________   Date: ____/____/______

Clinician Authorization

Clinician Signature: _________________________   Credentials: _________   Date: ____/____/______

(If any critical field is missing, display the red "NOT COMPLETE—DO NOT USE UNTIL VERIFIED" banner at top.)