ࡱ> HJG) !bjbj *6dddd    8C$g4 HJJJJJJ$ #nJ@n^HH@40M$M$M$HnnM$ : NEW YORK STATE DEPARMTENT OF HEALTH Bureau of Community Environmental Health and Food ProtectionEpinephrine Administration Childrens Camp Program Instructions: See Instructions on back of form prior to completing  eHIPS Incident Number: ____________ FACILITY INFORMATION Camp Name:____________________________________________________________ Facility Code:____________________________ Camp Type: ( Day ( Overnight Camp for developmentally disabled? ( Yes ( No Date Reported_______/______/______ to Local Health Department Incident Date: _____/_____/_____ Incident Time: _______:_______ (Military time) Location of Incident: ( In Camp ( Out-of-Camp Specify:_____________________________________________________________ Does the camp participate in the Epinephrine administration program? ( Yes ( No VICTIM INFORMATION eHIPS Victim ID: _____________ Name of Patient: __________________________________________________________________________________________________ Home Address Street ______________________________________________________________________________________________ Town, Village or City ________________________________________________________State___________________________________ Name of Parent or Guardian _________________________________________________________________________________________ Home Phone Number ( __ ) __________________________ Material in shaded area is confidential Age: ______ Weight:______ Sex: ( Female ( Male Status: ( Camper ( Developmentally Disabled Camper ( CIT/Jr. Counselor ( Counselor ( Other Staff* ( Other* ______________________ Specify for *___________________________ EVENT INFORMATION Type of Incident Resulting in Need to Administer Epinephrine: ( Bee Sting ( Other Insect Bite * ( Asthma Attack ( Food Allergy* ( Other* * Specify:________________________________________________________________________________________________________ Time Epinephrine administered: ____:_____ (Military time) Number of auto-injector administrations:______________________ Type of Epinephrine Injector: ( Epi-pen ( Epi-pen Jr. ( Other Specify:________________________________________ Where on body was epinephrine injected?______________________________________________________________________________ Indicate source of Epinephrine: ( Camp Supply ( Patient Prescription ( EMS supply ( Hospital Supply ( Other Specify:_________________________________ Epinephrine Administered by: Name:______________________________________ Indicate applicable certification(s) below ( Doctor ( Nurse Practitioner ( Physicians Assistant ( RN ( LPN ( EMT ( First Aid Certified Staff ( Self-Administered ( Other ____________________________________________ Epinephrine training course: ( NYS EMS ( Red Cross ( None ( Other ______________________________________ Name of EMS agency providing care:____________________________________________Phone:________________________________ Name and location of health care facility patient was transported to:__________________________________________________________ Was patient admitted? ( Yes ( No Narrative: Provide a written description of the event on back of form.  Instructions for completing the Childrens Camp Epinephrine Administration Report Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure. Childrens camps must report epinephrine administration to the local health department whether or not they are participating in the auto injector program and regardless if medication was from the camps stocked supply or brought to camp by a camper or staff. Description of Incident: Describe symptoms and circumstances surrounding the administration of the Epinephrine including the cause of anaphylaxis, signs and symptoms displayed by the patient prior to administration and the patients response to the administered drug. Enter the events in the chronological order of their occurrence. Include available information about the events outcome such as whether the patient was discharged from the hospital, returned to camp or went home. Use additional sheets if needed. When entering the narrative into eHIPS do not enter confidential information. Use the victims initials or similar code. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________ Report completed by:_____________________________________ Title:___________________________ Date: ______/______/______ Local Health Department:___________________________________________________________ Phone: (______)_________________     DOH-61e (3/18) #$MNb~   h i j q r t x y &( h-*>*CJhLh-*5CJaJ h$CJ jh$CJhLh-*CJaJjh-*CJUmHnHu h-*CJjh-*CJUmHnHu h-*CJ$ h-*5CJ$ h-*5CJh-* h-*CJ8bo^\Z\HkdL$$Ifl40L,\ \4 laf4Hkd$$Ifl40L,\`\4 laf4 $$Ifa$$If  % & $ J   x y ' ( /dx$d%d&d'd-D M NOPQ,$d%d&d'd-D M NOPQ P(   ?@oo3 Pb~ HrP .!(#$d&(*Z-:2`^2``/dx$d%d&d'd-D M NOPQ,$d%d&d'd-D M NOPQ ()45?@GIJKLVWXyz{|}WXYZfgh}~߿h$h-*CJaJh7jh-*CJaJ h-*CJ h$CJ jh$CJ h-*5CJhLh-*CJaJ h-*CJ jh7jCJEWX!./'(wyb  @`` p^p`gd^xgd^  ()*>@ABCwx RT h-*h h-*5h h-*5CJhLh-*CJaJ h$CJ jh$CJ hLCJ h-*CJ h^CJJbc  RT?6c d$a$b c ! !'!+!C!Z!!!!!!!!!!!!!!!!!!!!! hc'CJ h-*CJh,(_jh,(_Uh-* h-*5CJ h-*CJ h-*CJ h[[5 h-*5 h-*h h-*CJh% B!C!!!!!!!!!!!!!!#$d%d&d'dNOPQ(/ =!@"#$.% J$$If!vh#v\:V l4+5\4f4J$$If!vh#v\:V l4+5\4f4w666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666_HmH nH sH tH D`D NormalCJOJQJ_HmH sH tH <@<  Heading 1$@&5CJ<@<  Heading 2$@&5CJDA D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List 4 @4 Footer  !44 Header  !HH ^0 Balloon TextCJOJQJ^JaJN/!N ^0Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] 6 "(!( b !8@f(  bB  S DԔ#" ?bB  S D1#" ?B S  ?","tB+Bt+1DG5 ?  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