Anaphylaxis Field Trip Emergency Protocol Form
Date of Field Trip:
Destination:
Teacher/Staff in Charge:
Student Name:
Student D.O.B.:
Allergies (specify allergens):
Symptoms of Anaphylaxis:
Emergency Contacts
Name
Relationship
Phone Number(s)
Medication/Epinephrine Auto-Injector
Location of Auto-Injector during trip:
Dosage Instructions:
Who is responsible for carrying/administering medication?
Emergency Action Plan Steps
Nearest Emergency Hospital:
Additional Notes:
Prepared by (name & position):
Date Prepared: