The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

jXAp5fpheTCqNMMDcBeYzgkZaLaeX3HSuNIbjKY3BUJ292S27eQVvjp632REBHdtmWoGCcbwa6oaXLnD23MvnnzrCfamWkDLwomTIkLJqSpcbbJkuXi9WUHC9azHI

Epinephrine Administration Report

Returning?

A A A

Please complete the information requested, then click Next Page at the bottom of the page and continue on to the next page of the report. Repeat until you get to the last page of the report, then click Submit. To save your data and finish the report later, click Save and Return Later and follow the instructions on the page that pops up.

1. Person completing the report

* must provide value

Position

Address

Town

Zip Code

3. Phone Number

4. Email Address

* must provide value

5. Type of School District or School
Select the choice that best describes your district or school (Scroll down the drop-down list to see all the options).

* must provide value

6. Name of School District
If your district does not appear in the list or if you are unsure which district name to select, select "Other" from the list and enter the district in the box below.
Select an option

* must provide value

Other school district (Specify):

* must provide value

7. School Name
Enter the FULL NAME of the school building (in which the epinephrine was administered,
or in which the student was enrolled). Please do not use acronyms or
abbreviations since we will not know how to interpret them.

8. School address

City or Town

9. Age of person given epinephrine (at the time the epinephrine was administered) Specify age in years

10. Type of Person

* must provide value

Student

Staff

Visitor

Don't Know

Other

reset

11. Assigned sex at birth

* must provide value

Male

Female

Other

Don't Know

reset

Other (Describe):

12. Ethnicity: Spanish/Hispanic/Latino

* must provide value

Yes

Don't Know

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13. Race

* must provide value

Other (Specify):

14. Does the person have a history of ANY known allergies?

* must provide value

Yes

Don't Know

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15. Previously known allergies
(Check all that apply)

* must provide value

Food

Insect Sting

Exercise

Medication

Latex

Unidentified

None

Other (Specify):

16. Type of food allergies
(Check all that apply)

Cow's milk

Soy

Egg

Wheat

Peanut

Tree nuts

Finfish (fish with fins, excludes shellfish)

Shellfish

Sesame

Fruit

Legumes (other than peanut and soy)

Unknown

Other (Specify):

17. Was there an allergy action plan or Individual Health Care Plan (IHCP) in place?

Yes

Don't Know

Not Applicable / There was no history of allergy

reset

18. History of Anaphylaxis?

* must provide value

Yes

Unknown

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To save your report so you can finish it or edit it later, click Save & Return Later, save the Return Code, and then bookmark this page and re-name the bookmark so it includes the date (For example: “Epinephrine admin report-Oct 15”). You can also have the Survey Link for this report sent to your email address. To do that, just follow the instructions on the screen that pops up after you click Save & Return Later. If you need to edit your report later but do not have the Survey Link and have not bookmarked the page, then you will not be able to edit your report and you will need to re-submit the report and re-enter all of your data. When we receive more than 1 report for the same incident, we save only the more recently submitted report and discard any earlier reports.

Save a copy of your report before you submit it. We will not be able to retrieve your report and send it to you. You can download a pdf copy of the report after you click Submit, but to save a more readable copy, before you click Submit, print each page to a pdf file or print a hard copy of each page (right-click on the page and select Print).

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.