Children with allergies who may need epinephrine or an antihistamine in Maryland child care use this plan in place of OCC 1216. The health care provider completes page 1 with the allergen exposure route, history of anaphylaxis and asthma, symptom-based treatment orders and the medicines to give, and the program follows it for up to one year.
The authorized health care provider completes page 1 and signs the prescriber line. The parent completes the authorization and emergency contacts on page 2, and child care staff complete the checklist and administration record.
Download the current version from the source each time; forms change without notice.
Allergy and Anaphylaxis Medication Administration Authorization Plan
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Yes. The form states it is for allergy and anaphylaxis medication only and replaces OCC 1216. It combines the treatment plan, the prescriber's authorization, parent consent, emergency contacts and a medication administration record.
Staff give epinephrine right away and note the time, call 911 and ask for an ambulance with epinephrine, stay with the child, call the parents, keep the child lying on the back or on the side if vomiting or struggling to breathe, and give other prescribed medicine.
The provider marks yes or no for self-carry and for self-administration on page 1. The parent's section notes that the child care program may revoke a child's authorization to self-carry or self-administer medication.