Colorado's statewide standard form combines a student's allergy and anaphylaxis emergency care plan with the provider's medication orders for epinephrine and any antihistamine. Green, yellow and red zones tell school staff when to give epinephrine and call 911. Under C.R.S. 22-1-119.5, a treatment plan is effective only for the school year in which it is approved, so it is renewed each year.
The student's physician, NP or PA completes the healthcare provider section: epinephrine product and dose, second-dose instruction, antihistamine, asthma status and self-administration, then prints their name and signs. The parent signs consent and a liability release, and the school nurse signs and notes any self-carry contract or meal modification form.
Download the current version from the source each time; forms change without notice.
Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders
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One school year. The form cites C.R.S. 22-1-119.5, which says a treatment plan is effective only for the school year in which it is approved, and the top of the form records the school year. A new plan with fresh provider orders is needed for each school year.
Yes, if the provider marks Self-administer: Yes, confirming the student has been instructed and can carry and self-administer their own emergency epinephrine. The school nurse notes whether a self-carry contract is on file; CDE posts the contract in English and Spanish. A trained staff member must remain available in case the student cannot self-administer.