Epinephrine Administration Report

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Massachusetts Department of Public Health

To save your data and finish the report later, click Save and Return Later at the bottom of the page and follow the instructions on the page that pops up.

Epinephrine Administration Report Guide

When Should You Submit this Epinephrine Administration Report?

105 CMR 210.010(A)(7)(j) and 105 CMR 210.009(C) require the reporting of epinephrine administration in schools. This applies to all Massachusetts schools, including both nonpublic and public, during "regular school activities". 105 CMR 210 states that "Regular School Activities means all instructional/academic activities, as well as all activities organized or sanctioned by the school including, but not limited to, day and overnight field trips, school-provided transportation, interscholastic sporting events, after school or extracurricular clubs or organizations, and proms or other social events organized as part of the instructional/academic portion of the school."

FAQ

1. Do I need to report when Emergency Medical Services (EMS) administers epinephrine at a regular school activity?
It depends! Was it at school or was it in an ambulance? If it was administered at school, yes. If it was on the ambulance, no. We also understand that as a nurse you may not be around when it is administered by EMS, so if you aren't aware, we understand that you cannot report.

2. Do public and nonpublic Massachusetts schools need to report when epinephrine is administered on an out of state school field trip?
Yes, this applies to all Massachusetts schools during regular school activities.

3. Do I need to report when epinephrine is administered on a field trip to Massachusetts when we are NOT a Massachusetts (either public or nonpublic) School?
No, this applies only to Massachusetts schools.

4. Do I need to submit a report if epinephrine was administered for any reason other than anaphylaxis (including accidental discharge)?
Yes, this report needs to be submitted every time epinephrine is administered during regular school activities of Massachusetts schools.

For questions, please email medication.delegation@mass.gov.

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).

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.

* must provide value

8. School address

City or Town

9. Age of student (or other person) having an allergic reaction or to whom epinephrine was administered.
Specify age in years at the time the epinephrine was administered

10. Type of Person

* must provide value

Student

Staff

Visitor

Don't Know

Other

Epinephrine Administration Report

Massachusetts Department of Public Health

If you did not take the patient's temperature, please delete the 0 you just entered and leave this field blank.

If the patient really did have a temp of 0°F please leave the 0 there.

Are you sure that this patient's temperature was ______°F?

Did you enter the correct expiration date? The date entered indicates that the epinephrine that was administered was expired.

If the expiration month is known but the expiration day is not indicated on the dose, please enter the last day of the month in which the Epinephrine expires.

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