Procedures and Guidelines for Managing Potentially Life-Threatening Allergies in School

Transcription

1 Procedures and Guidelines for Managing Potentially Life-Threatening Allergies in School 2014 GAC /25/14 1

2 Contents Acknowledgment 4 Introduction 5 Food and Other Potentially Life-Threatening Allergies 6 Food Allergies 7 Characteristics of Allergic Reactions 8 Importance of Prevention 9 Cross-Contamination 10 Cleaning and Sanitation 10 Food Allergies in School 11 Older Students with Food Allergies 12 Other Types of Allergies 13 Overview of Laws 14 School Guidelines and Checklists 18 General Guidelines 19 CCSD Procedures -Creating a Safer Environment for Students with Potentially Life-Threatening Allergies 21 Medical Alerts 21 Licensed Health Care Provider Orders 22 Self-Administration of Prescribed Medication 22 Administration of Injectable Epinephrine 22 Stock Epinephrine 23 Section 504 Accommodation Plan 23 School Nurse Guidelines 24 School Nurse Checklist 24 Field Trip Procedures 26 Return to School Post-Reaction Checklist 27 Preparing for an Emergency 28 School Administration Guidelines 29 School Administration Checklist 29 Parent/Guardian Guidelines 32 Parent/Guardian of Children with Food Allergies Checklist 32 2

3 Contents Student Guidelines 34 Students with Food or Other Life-Threatening Allergies Checklist 34 Classroom Teacher/Specialist Guidelines 35 Classroom Teacher/Specialist Checklist 35 Classroom Activities Checklist 36 Classroom Snack Checklist 37 Field Trip Checklist 38 Field Trip Medication Checklist 38 Food Service Guidelines 39 CCSD Food Service Special Diet Request 40 CCSD Medical Statement to Request a Special Diet 41 Food Service Checklist Cafeteria Personnel/Student Workers 42 Cafeteria Checklist Monitors and Custodial Staff 43 Operations/Custodial Staff Guidelines 44 Custodial Staff Checklist 44 Operations Verification of Training 45 Cafeteria Table Sanitizing Procedures 46 Ordering Information 47 Cafeteria Sanitizing Procedure 48 Cafeteria Table Sanitizing Procedure 49 Outside of Classroom Activities Guidelines 50 Other Instructional Areas/Lunch/Recess Monitors Checklist 50 Coaches/Activity Leaders/Athletics Checklist 51 Transportation Guidelines 52 Transportation Notification 55 Training Checklist for Bus Drivers and Bus Aides 57 Student Health Care Plan/Medical Alert 58 Resources 60 Appendix A: Sensitivity and Bullying 61 Appendix B: Reading Food Labels 62 Appendix C: Constructive Classroom Rewards 63 Appendix D: Emotional Wellness, Children with Potentially Life-Threatening Allergies 66 Appendix E: Food Allergy Tips for PTA Leaders 67 Appendix F: School Nurse Resource Samples 68 Appendix G: Additional Resources 73 Appendix H: Glossary 74 Appendix I: References 77 3

4 Acknowledgement The Clark County School District Student Services Division provided leadership, coordination and management in the development of this document. This Division will continue to be responsible for the required updates and revisions. The task force creating these procedures reviewed and closely followed The Guidelines for Managing Life-Threatening Food Allergies in Illinois Schools. These guidelines are based on best practices and additional medical documents. The task force included representatives from the following groups: Food Allergy Experts Administrators Principals Instruction Unit Office of Compliance and Monitoring Food Service Department Transportation Department Operations Department Office of the General Counsel Equity & Diversity Education Department Health Services Department Related Services Department Guidance and Counseling Department Parents Food Allergy Research & Education (FARE) Representatives This project was made possible through a community grant from Food Allery Research & Education (FARE) 4

5 Introduction Food allergies and other types of potentially life-threatening allergies present an increasing challenge for schools. Lack of outward indicators makes it difficult to identify students at risk for a life-threatening reaction, and the severity of an allergic reaction cannot be predicted. Because of the potentially lifethreatening nature of these allergies and their increasing prevalence, school districts and individual schools must be prepared to provide treatment to students with food and other life-threatening allergies, reduce the risk of food and other life-threatening reactions and accommodate these students. Every food-allergic reaction has the possibility of developing into a life-threatening and potentially fatal anaphylactic reaction. This can occur within minutes of exposure to the allergen. (Sampson, HA, Food Allergy, from Biology Toward Therapy, Hospital Practice, 2000) 5

6 Food and Other Potentially Life-Threatening Allergies 6

7 Food Allergies Food Allergies on the Rise Food allergies affect 8% of children under 18 and 4% of adults. Allergy prevalence has increased significantly since Every food-allergic reaction has the possibility of developing into a life-threatening reaction and, even with proper treatment, can be fatal. A life-threatening reaction can occur within minutes or hours after exposure to the allergen. Some individuals may react to just touching or inhaling the allergen while, for others, consumption of a miniscule amount of an allergenic food can cause death. The emotional, as well as the physical, needs of the child must be respected. A student s behavior may be drastically altered by their fear of a reaction. School nurses or guidance counselors should be available to work with families of students with potentially life-threatening allergies. Students with food allergies are at-risk for eating disorders and/or teasing. For example, a student may choose not to eat rather than risk embarrassment from a reaction in front of a peer. Working with Families The best practice is for all students with food allergies to have an individualized Medical Alert and 504 Plan (if indicated) in place. Schools can provide invaluable resources to students with food allergies and their families by helping students feel accepted within the school community. They can provide instruction/ support in the following areas: Keeping them safe. Asking for help, and learning how to trust others. Developing healthy and strong friendships. Acquiring social skills. Improving their self-esteem. Increasing their self-confidence. Raising a child with life-threatening allergies is challenging. Parents must ensure strict food avoidance, understand food labeling, and be on constant alert. Parents of children with food allergies have crafted ways to keep their children safe in a world that is not presently food-allergy friendly. As their children grow and their world expands, so do the demands for parents to re-adjust their own thinking and strategies for maintaining a normal, safe environment for their children. The threat to this balance is never greater than when a child begins school. What had worked so well in their own home is now being entrusted to unfamiliar people, who may or may not be knowledgeable about food allergies and supportive of parents. 7

8 Characteristics of Allergic Reactions Allergic reactions to foods vary and can range from mild reactions to severe, life- threatening reactions. Bee or insect stings, medications and latex also have the potential of causing life-threatening reactions. During an allergic reaction to a specific food, the immune system recognizes a specific food protein as a target. This initiates a sequence of events in the cells of the immune system resulting in the release of chemical mediators, such as histamine. Ingestion of a food allergen is the principal route of exposure leading to an allergic reaction. The symptoms of a food-allergic reaction are specific to each individual. Even a trace amount of food can, in some instances, quickly lead to fatal reactions. Research indicates that exposure to food allergens by touch or inhalation is unlikely to cause a life-threatening reaction. However, if children touch the allergen and then place their fingers in or near their nose or mouth, the allergen could become ingested and could cause a life-threatening reaction. Allergies can affect almost any part of the body and can cause various symptoms. Anaphylaxis involves the most dangerous symptoms, including, but not limited to, breathing difficulties, a drop in blood pressure, or shock, all of which are potentially fatal. Common signs and symptoms of allergic/anaphylactic reactions may include: Hives Itching (of any part of body) Runny nose Vomiting Diarrhea Stomach cramps Change of voice/hoarseness Coughing Wheezing Throat tightness or closing Swelling (of any body parts) Red, watery eyes Difficulty swallowing Difficulty breathing Sense of doom Turning blue Drop in blood pressure Feeling faint, confused, weak Loss of consciousness Chest pain A weak or thready pulse A child may be unable to describe his/her reaction the way an adult might expect. Here are a few ways children might express or state their allergic reaction. Exhibit screaming or crying. Very young children will put their hands in their mouths or pull at their tongues. This food s too spicy. It burns my mouth (or lips). There s something stuck in my throat. My tongue and throat feel thick. My mouth feels funny. I feel funny (or sick). 8

9 When the symptoms are rapid in onset and severity, the medical diagnosis is anaphylaxis. With anaphylaxis there is always the risk of death. Death could be immediate or may happen two to four hours later due to a late- phase reaction. The most dangerous symptoms include breathing difficulties and a drop in blood pressure leading to shock. A single dose from an epinephrine auto-injector may provide a minute (or less) window of relief. A second dose of epinephrine may be required if symptoms do not lessen or if medical help does not arrive quickly. A large multicenter study showed that 12% of children requiring epinephrine for a life-threatening reaction to food required a second dose. It is imperative that following the administration of epinephrine, the student be transported by emergency medical services (EMS) to the nearest hospital emergency department even if symptoms have been resolved. Some high-risk situations for a student with food allergies include: Cafeteria Hidden ingredients Arts and crafts projects Anaphylaxis appears to be much more likely among children who have already experienced an anaphylactic reaction from one or more previous allergic incidents. Anaphylaxis does not require the presence of any skin symptoms, such as itching or hives. In many fatal reactions the initial symptoms of anaphylaxis were mistaken for asthma. When in doubt, it is important to utilize an epinephrine auto-injector and seek medical attention. Fatalities have been associated with delay in epinephrine administration. Importance of Prevention School is a high-risk setting for accidental exposure to food allergens. School district procedures must be in place at school to address allergy issues during a variety of activities. The importance of reading and understanding a Medical Alert and 504 Plan (if indicated), for a student with potentially life-threatening allergies, cannot be stressed enough. These documents help all school personnel understand the accommodations necessary to keep that specific student safe. Substitute teaching staff must be made aware of and understand the accommodations necessary for a student with potentially life-threatening allergies. Science projects Bus transportation Fundraisers Bake sales Parties and holiday celebrations Field trips Food/beverages brought into classroom by teachers/ parents Goodie bags sent home with children Dances, sporting events, after-school extracurricular activities Protecting a student from exposure to offending allergens is the most important way to prevent life-threatening anaphylaxis. Most anaphylactic reactions occur when a child is accidentally exposed to a substance to which he/she is allergic, such as foods, medicines, insects, and latex. More than 15% of school aged children with food allergies have had a reaction in school. Avoidance is the key to preventing a reaction. 9

10 Cross-Contamination Cross-contamination happens when different foods are prepared, cooked, or served using the same utensils and surfaces. When preparing and serving food, it is critical to make sure that food preparation and serving utensils are not exposed to allergens and then used for another food. Food production surface areas must be cleaned before, during, and after food preparation. Some examples of cross-contamination would be: Lifting peanut butter cookies with a spatula and then using the same spatula to lift sugar cookies. Using a knife to make peanut butter sandwiches, wiping the knife, and then using that same knife to spread mustard on a student s cheese sandwich. Cleaning and Sanitation Any surfaces used for the preparation and service of meals must be properly cleaned and sanitized. For preparation areas, the work surface and all utensils and pots and pans must be washed with hot soapy water. Work surface areas, counters, and cutting surfaces need to be cleaned thoroughly between uses. The use of the color-coded cutting board system implemented for food safety can also help minimize the risk of crosscontamination when preparing foods for students with food allergies. Examples include: After using a food slicer to slice cheese, the slicer must be cleaned thoroughly before being used to slice other foods to prevent contamination with cheese protein. Wash trays or cookie sheets after each use, as oils can seep through wax paper or other liners and contaminate the next food cooked on the sheet or tray. Allergens must be physically removed from the surface using CCSD approved cleaning agent. Dishwashing liquid has been shown to leave traces of the allergen on tables. Do NOT use dishwashing liquid to clean surface areas. At home common household cleaning agents, such as Formula 409, Lysol sanitizing wipes, and Target brand cleaners with bleach, have successfully removed allergens from table tops. (Perry TT, Conover-Walker MK. Journal of Allergy and Clinical Immunology.) 10

11 Food Allergies in School While there are many possible reactions to food, it is important to understand why a food allergy is different. Individuals with a food allergy have an immediate, immune-mediated reaction to specific foods. Although any food can cause a food allergy, the most common food allergies in childhood are milk, egg and peanut. Other common allergens include wheat, soy, fish, shellfish and tree nuts. Allergies to seeds, such as sesame and mustard, also seem to be on the rise. When a child has a food allergy, the only current management to prevent a reaction is strict avoidance. Children may have life-threatening reactions with the ingestion of even very small amounts of a food allergen. This may happen when foods are cross-contaminated, or when food labels are not accurate or available. Some foods contain unexpected ingredients, such as milk protein in low fat luncheon meats. Adults responsible for students with food allergies must be familiar with the student s individual Medical Alert and 504 Plan. These plans contain the specific actions necessary to keep the student safe. All complaints from students with food allergies are to be taken seriously. Delay in treatment could be fatal. There are some general considerations for students with food allergies. Remember, students with food allergies are children, first and foremost. Do not ask them if it is acceptable to deviate from any of their individual plans. Be aware of signs of anxiety or bullying. Also, younger students are more likely to put their hands and/or items in their mouths and may require food-free or allergen-free classrooms. This may include everyone thoroughly cleaning their hands before entering the classroom and after eating. Be aware that even a small amount of milk present as creamer in coffee may be an issue, so everyone who enters the classroom must be aware of and follow the student s individual plan. Accidents are more likely to happen when there is an unplanned event, such as an unplanned celebration with food. School procedures should be in place to avoid unplanned food events. It is essential that the student s Medical Alert and 504 Plan are followed exactly. If you have questions, ask the school nurse before allowing any changes. This also applies to changes which may not directly involve eating. School personnel should be aware of common symptoms of a food-allergic reactions including itchy rash or hives, throat clearing, difficulty breathing or swallowing, repetitive cough, vomiting, and swelling of the face or limbs. Additionally, school personnel should be aware of the student s individualized allergic symptoms which will be included on their Medical Alert. These symptoms are more likely to happen within 2-4 hours of eating and usually progress rapidly. Studies have shown that accidental food exposures do occur in the school setting. Even with the best of plans, accidental ingestions may happen. All complaints from students with food allergies are to be taken seriously and evaluated according to their Medical Alert or 504 Plan. Know your role in treating a student s symptoms and how to get help should a reaction happen. Do not delay! Delay in receiving the appropriate medication (epinephrine) for an allergic reaction has been the key contributor to food allergy fatalities. Senate Bill 453 became effective on 7/1/13 and now requires all Nevada schools to maintain epinephrine auto injectors, without an individual prescription, (stock epi-pens) at every site and train personnel in both the recognition of symptoms of anaphylaxis and the administration of the epinephrine auto injector on the school campus during school hours. 11

12 Older Students with Food Allergies Teens with food allergies have unique needs because of the turbulent nature of the teenage years and the characteristics of a typical day of a middle school or high school student. As a result, additional factors need to be regarded at the secondary school level in order to provide the best care for food-allergic teens. The school team should consider the factors below when developing the school s food-allergy procedures, as it pertains to teens with food allergies. Students move to different classrooms, frequently in larger buildings and campuses, presenting needs for updated avoidance strategies, epinephrine availability, and designated assistance. Students may have access to vending machines. Certain classes give rise to new avoidance issues. (i.e., chemistry/biology labs, home economics/ culinary class, etc.) The number of off-site school-sponsored functions increases. (i.e., travel, sometimes to other states and foreign countries; athletic games and competitions, sometimes in other towns; dances; etc.) Risk-taking behaviors frequently accompany the independence of adolescent years. Identify appropriate staff for the emergency administration of the epinephrine auto-injector even when a student is able to self-administer life-saving medication. Although teenage students will more than likely be permitted to carry and self-administer emergency medications, those students must not be expected to have complete responsibility for the administration of the epinephrine auto-injector. A severe allergic reaction can completely incapacitate a student and inhibit the ability to self-administer emergency medication. A trained school staff member must be available during school and school-sponsored functions to administer the epinephrine auto-injector in an emergency. 12

13 Other Types of Allergies Other Types of Allergic Reactions including yet not limited to: Venom, Latex and Medication Information and awareness procedures apply fully for students with other types of potentially anaphylactic allergies. These include the development and implementation of a Medical Alert and 504 Plan (if indicated). Specific avoidance measures will depend on the allergic condition, as noted below; Avoidance Measures for Insect Venom/Stings Allergic Reactions The student should avoid wearing loose, hanging clothes, floral patterns, blue and yellow clothing, fragrances. Check for the presence of bees and wasps, especially nesting areas, and arrange for their removal. Ensure garbage is properly covered and away from play areas. Caution students not to throw sticks or stones at insect nests. If required by a Medical Alert and/or 504 Plan, allow students with life-threatening insect allergies to remain indoors for recess during bee/wasp season, if requested. Immediately remove a student with allergy to insect venom from the room if a bee or wasp gets in. In case of insect stings, never slap or brush the insect off, and never pinch the stinger if the student is stung. Instead, flick the stinger out with a fingernail or credit card. Avoidance Measures for Latex Allergic Reactions Inform school administrators and teachers of the presence of students with latex allergies. Identify areas of potential exposure and determine student risk. Screen instructional, cafeteria and maintenance department purchases to avoid latex products. Eating food that has been handled by latex gloves presents a high risk of a reaction. Do not use latex gloves or other latex products for students with latex allergies. Do not allow the use of latex balloons for celebrations in schools where a student has a latex allergy. When medically indicated, consider posting signs at school entry ways Latex precautions in place here. Suggestions for Medication Allergic Reactions Maintain current health records with information regarding medication allergies. With the exception of stock epinephrine, do not administer a medication to a student unless there is an order/request. This includes over-the-counter medications (OTC) like ibuprofen or aspirin. Refer and adhere to school district medication policy. 13

14 Overview of Laws Potential Legal Consequences Schools are prohibited by federal law from discriminating against students with food allergies and are required to provide them with the same educational services and activities that other students receive. While the students are in the custody of the school, the district is required to take reasonable steps to ensure their safety. Since food allergies are potentially deadly, the consequences of a school s negligence in protecting a food-allergic student could result in legal and financial liability. For that reason, a food allergy plan should be developed for any student diagnosed with a food or other potentially life-threatening allergy. An Overview of Laws Requiring Schools to Protect Food-Allergic Students Certain federal laws govern the school district s responsibilities for meeting the needs of students with severe food allergies and other forms of anaphylaxis. These guidelines are in addition to, and not in lieu of, those federal laws. The school district has an obligation to seek suitable means of reasonably accommodating a student upon notification and confirmation of potentially life-threatening food allergies and to keep a record indicating that the school conscientiously carried out this obligation. Included in this duty is an obligation to gather sufficient information from the food-allergic student and qualified expert assessments as needed to determine what accommodations are necessary. Each student with a potentially life-threatening allergy is different and will require a different individualized plan based on a variety of factors, including his or her food or other allergies, age, medical history, recommendations from doctors, and facilities in the school. Sometimes a student s individual needs will require the school to take more precautions and to make more accommodations than are required by these general guidelines. Section 504 of the Rehabilitation Act of 1973 ( Section 504 ) Section 504 prohibits all programs and activities receiving federal financial assistance, including all public schools and some private schools, from discriminating against students with disabilities, as defined in the law. A student with a disability under Section 504 is defined as one who has a physical or mental health impairment (in this case, life-threatening anaphylaxis) that substantially limits a major life activity. (29 U.S.C. 794; 34 C.F.R. 104, et seq.). Major life activities covered by this definition include, but are not limited to, caring for one s self, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. Major life activities also include the operation of major bodily functions, including, but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. Food allergies may affect multiple major life activities and bodily functions. Substantially limited is not defined in Section 504 regulations. In order to determine eligibility criteria as outlined in the regulations, an individual assessment of the student is required. Districts must now make their Section 504 determination, based upon the child s disability as it presents itself without mitigating measures (hearing aids, medications, mobility devices, etc.). The Office of Civil Rights (OCR) has now determined that health plans are mitigating measures (2009), and evaluations for initial 504 Plans must consider more than the life activity of learning. The CCSD Office of Compliance and Monitoring has determined that CCSD teams must consider a life-threatening allergy as a disabling condition. CCSD will provide 504 Accommodation Plans for students with food allergies and chemical sensitivities. 14

15 If qualified for a 504 Plan, the student is entitled to receive a free, appropriate public education (FAPE), including related services. These services should occur within the student s usual school setting with as little disruption as possible to the school s and the student s routines, in a way that ensures that the student with a disability is educated and able to participate in school activities to the maximum extent possible with the student s non-disabled peers. Schools must develop a plan to accommodate students who qualify under Section 504, referenced herein as a 504 Plan. The FAPE standard is generally satisfied by following The U.S. Department of Education s implementing regulations for the Individuals with Disabilities Education Act ( IDEA ), which refer to handicapped persons. (See IDEA discussion below.) The CCSD Office of Compliance & Monitoring has provided updated information and training regarding Section 504 protections and accommodations for students with food and other potentially life threatening allergies. This information was developed for training purposes and will be included in the annual Section 504 trainings provided for school liaisons. Title II of The Americans with Disabilities Act (the ADA ) of 1990 Like Section 504, the ADA also prohibits discrimination against any individual with a disability, and extends the Section 504 requirements into the private sector. The ADA contains a definition of individual with a disability that is almost identical to the Section 504 definition. The ADA also provides a definition of substantially limits (42 U.S.C et seq.; 29 C.F.R et seq.). The Americans with Disabilities Act Amendments Act of 2008 (the ADAAA ) The ADAAA made significant changes to the ADA s definition of disability by broadening the scope of coverage (i.e., broadening what qualifies as a disability ) and limiting consideration of the ameliorative effects of mitigating measures (i.e., medication or learned behavioral modifications). The ADAAA also overturned a series of U.S. Supreme Court decisions that interpreted the Americans with Disabilities Act of 1990 in a way that made it difficult to prove that impairments were a disability. Individuals with Disabilities Education Act ( IDEA ) School districts are required to provide special education and related services to students who are covered by IDEA. IDEA is different from the ADA and Section 504, because it relates to the accommodations a school must make in the individualized education and curriculum of a student with a disability, not just the ability of the student to attend school classes and activities with other students. A qualifying disability under Part B of IDEA is different than the term disability under Section 504. Under IDEA, a student with a disability means: 1) the student was evaluated in accordance with IDEA, 2) has one or more of the recognized 13 disability categories, and 3) because of the qualifying disability needs special education and related services. When a student qualifies for special education and related services under IDEA, schools must develop an Individualized Education Program ( IEP ) for the student. An IEP is a written plan for a student with a disability that is developed, reviewed, and revised in accordance with the IDEA and The U.S. Dept. of Education s implementing regulations. Typically, students with food allergies are accommodated through a Medical Alert and Section 504 Plan and not an IEP. However, food allergies may contribute to a health impairment qualifying as a disability under IDEA or some students may qualify under IDEA for services and also have a food allergy, so it is important to note that in some unique circumstances, IDEA may be applicable in addition to Section 504 and the ADA. 15

16 United States Department of Agriculture ( USDA ) Regulations: For schools participating in a federally-funded student nutrition program, USDA regulations 7 CFR Part 15b require substitutions or modifications in school meals for students whose disabilities restrict their diets. A student with a disability must be provided substitutions in foods when that need is supported by a statement signed by a licensed health care provider. The physician s statement must identify: The student s disability An explanation of why the disability restricts the student s diet The major life-activity affected by the disability The food or foods to be omitted from the student s diet, and The food or choice of foods that must be substituted USDA regulations 7 CFR also require schools to develop and support a Student Wellness Policy in compliance with the Nevada Department of Education Statewide School Wellness Policy as well as the Healthy, Hunger Free Kids Act of This policy applies to ALL food and beverages sold or given away to students from one-half hour before school starts until one-half hour after the end of the regular school day. Office for Civil Rights Letters The Office for Civil Rights ( OCR ) promotes and ensures that people have equal access to and opportunity to participate in certain federally funded programs without facing unlawful discrimination. Two of OCR s legal authorities include Section 504 and Title II of the ADA. At times, OCR provides letters, which can be used by school districts for guidance. These letters, however, are not published, but may be available where they have been submitted for publication in a private service or posted on an Internet site. Nevada Revised Statutes Assembly Bill (AB) 182 became effective in July This law (NRS ) requires principals and school nurses to allow students to self-administer prescribed medications for asthma and anaphylaxis (severe systemic allergic reaction) under certain circumstances. NRS was designed with rapid response and student safety in mind. Senate Bill 453 Senate Bill (SB) 453 became effective July 1, 2013 and requires all Nevada schools to maintain epinephrine auto injectors (stock epi-pens) at every site and train personnel in both the recognition of symptoms of anaphylaxis and the administration of the epinephrine auto injector on the school campus during school hours. CCSD Regulation 5150 CCSD Regulation 5150 (revised 4/24/14) provides guidance in the management and administration of health services in the Clark County School District. Specifically, it provides direction regarding the management of medications for students during school hours. Section III C addresses the Self- Administration of Emergency Medications for Asthma and Anaphylaxis and provides specific procedures that were put in place by the District to conform to NRS , as referenced above. These procedures include a written request by the parent/guardian; a signed statement from the physician indicating the student has asthma or anaphylaxis and is capable of self-administration of the medication, as well as 16

17 parent acknowledgment regarding liability limitations. It further authorizes administration of emergency medication by a trained school staff member if the student exhibits signs and symptoms of anaphylaxis and is unable to self-administer the medication. The CCSD Health Services Department procedures and forms regarding the management of asthma and anaphylaxis and the provision of emergency medications provide the mechanism for obtaining the required information and signatures to conform to the Regulation. CCSD Regulation 5157 CCSD Regulation 5157 (revised 11/30/06) was developed to comply with the Nevada Department of Education Statewide School Wellness Policy as well as the Child Nutrition Program (CNP) and the Women, Infants, and Children (WIC) Reauthorization Act of The regulation is in effect in all schools in the CCSD and provides nutrition, beverage, and portion standards, as well as a variety of procedures related to approved foods and beverages, vending machines, and food sales outside of regular school hours. Additionally, information is provided regarding the school environment; nutrition and wellness education; and monitoring and accountability. The focus of the regulation is on improving student wellness based on the clear connection between good nutrition, student achievement, and classroom behavior. 17

18 School Guidelines and Checklists 18

19 General Guidelines This section serves as a guide for schools to outline the range of responsibilities school district staff have concerning a student with a life-threatening allergy. Note that each student s team ultimately determines the responsibilities of individual staff members. This guide will help teams determine which accommodations are necessary for a given student. The management of a student with potentially life-threatening allergies may be impacted by a number of factors, such as the age of the student, the allergens involved, and the facilities at the school. Recommended Best Practices for Schools The following are recommended best practices for schools: Address life-threatening allergic reaction prevention in all classrooms, food service areas/cafeteria, classroom projects, crafts, outdoor activity areas, on school buses, during field trips, before- and after-school activities and in all instructional areas. Adapt curriculum, awards, rewards, or prizes by substituting non-food item(s). It is recommended that schools completely remove food from the curriculum due to the number of students with food allergies and the variety of food allergies present within a school or classroom (Constructive Classroom Rewards-Appendix C). Limit food-related fundraising (Student Stores, Clubs, Sports Teams, PTA s, Kiosks and Vending Machine Inventories) to designated areas. Student organizations selling food should be comprised solely of students and staff, no vendors. Incorporate non-food items. Only approved snacks and beverages may be offered for sale to students through vending machines and student stores from one-half hour before school starts until onehalf hour after the end of the regular school day. The food sold must be commercially prepared and meet specified nutritional standards. NO homemade food should be sold or given away one-half hour before school starts until onehalf hour after the end of the regular school day. Lists of approved foods and beverages are available on the CCSD Food Service Department website and are updated monthly by the Clark County School District Food Service Department Registered Dietitian. School options include establishing allergen-free zones, such as a student s individual classroom, allergen-free lunch table(s) or areas in the cafeteria and food-free zones, such as libraries and music rooms. Student s classroom(s) must be a safe place for all students to learn. School procedures must enforce relevant school policies such as those that prohibit eating on the school bus. All vending contracts must be reviewed and approved by district legal counsel prior to being signed by the school principal. (CCSD Concessions/Vending Site Contract dated 5/24/2012). Establish cleaning procedures for common areas (e.g., libraries, computer labs, music room, art room, hallways, etc.). Avoid the use of food products as displays or components of displays in hallways. Follow CCSD Operations protocols for appropriate cleaning methods following events held at the school which involve food. Determine who should be familiar with the student s Medical Alert and 504 Plan. 19

20 Teach all faculty and staff about the signs and symptoms of possible anaphylaxis. This training should include: How to recognize symptoms of an allergic reaction. Review of high-risk areas. Steps to take to prevent exposure to allergens. How to respond to an emergency. How to administer an epinephrine auto-injector (designated trained volunteers). How to respond to a student with a known allergy as well as a student with a previously unknown allergy. Conduct an anaphylaxis emergency response drill at least yearly to establish effective response patterns. A number of resources are available for in-service training. Several organizations and pharmaceutical companies offer free training materials. See Appendix F for a list of helpful organizations and companies. Specific Guidelines for Different School Roles The following pages provide recommended best practices for individual responsibilities within the school. Additional reference material can be found in the Resource Section. The guidelines/checklists are grouped into eight major categories: School Nurse Procedures and Guidelines Administration Parent/Students Teacher Food Service Custodians Outside of Classroom Activities Transportation The general population has many misconceptions about food allergies. An appreciable food allergy knowledge gap exists, especially among physicians and the general public. The quality of life for children with food allergy and their families is significantly affected. The majority (54%) of people surveyed from the general public believe that food allergies can be cured (there is no cure). Almost a third (32%) believes that a daily medication can be taken to prevent a reaction (no such medication exists). Additional education is required to close the food allergy knowledge gap. (Gupta, et. al., BMC Pediatrics, 2008) 20

21 CCSD Procedures - Creating a Safer Environment for Students with Potentially Life-Threatening Allergies Life-threatening allergic reactions may result in anaphylaxis, a serious reaction which may occur over a period of minutes to hours and may affect multiple body systems. Anaphylaxis may occur in response to almost any foreign substance and can be fatal. The school nurse will provide training to staff members who work with those students known to have severe allergic reactions annually and more often if indicated. Training will include recognition of signs/symptoms of a reaction, including those specific to each identified student, student-specific allergens and known response, prevention of exposure to identified allergens, and treatment as prescribed by the licensed health care provider and as listed on the student s Medical Alert. Students with known serious reactions will need an action plan to address the types of allergens specific to the student, the symptoms known to occur (note: previous symptoms do not necessarily indicate future reaction symptoms either by type or severity) and treatment as ordered by the licensed health care provider. Upon receiving notice of a student who has a potentially life-threatening allergic reaction, the school nurse will contact the parent/guardian to discuss school management. The parent/guardian may be requested to provide consent for the school nurse to contact the licensed health care provider. Clark County School District action plans are based on the development of a Medical Alert individualized to each student s specific needs. The Medical Alert may be part of a Section 504 Accommodation Plan, if indicated. The action plan may also include a variety of checklists and medical information for the administration of medication if so ordered. Medical Alert The appropriate CCSD Medical Alert will be completed by the school nurse and distributed to those school staff members who work with the student during the school day and during school sponsored activities. The Medical Alert includes the following information: o o o o o o o Student s personally identifiable information Known allergens/triggers, via information provided by the parent/guardian and/or health care provider Student s known response to the allergen(s); note: previous response is not indicative of future responses, either by type or severity. List of typical signs/symptoms of life-threatening allergic reactions Standard action instructions to the teacher Educational/special considerations, both standard and individualized for the student List of staff members to whom a copy of the Medical Alert is provided. The CCSD Health Services Department has several standard Medical Alerts regarding anaphylaxis. o The Epi-Pen Medical Alert (HS-65A) specifically includes instructions for the administration of the Epi-Pen auto-injector. The Medical Alert is revised as needed during the school year. 21

22 Licensed Health Care Provider Orders Licensed health care provider orders are required for administration of any medication associated with the treatment of an allergic reaction. In Nevada, school nurses may accept orders from a physician, nurse practitioner or physician s assistant. The school nurse utilizes a template order form, Licensed Health Care Provider s Specialized Orders for Health Services at School: Anaphylaxis (HS-166). The form also includes a section which the parent/guardian must complete to request these health services during school activities. The orders provide the name and dosage of the medication and indications for use. Parent/guardian requests for changes in medication orders should be made through the licensed health care provider, who will communicate the changes to the school nurse. The parent/guardian section of the orders also permits the school nurse to contact the licensed health care provider as needed. Orders are renewed yearly or more frequently as needed. SB 453 requires a standing physician s order for the administration of stock epinephrine by trained staff. CCSD has obtained this standing order from the CCSD Medical Advisor, a licensed physician, and will update annually. Self-Administration of Prescribed Medication Nevada Revised Statute requires schools to allow students to self-administer prescribed medications for severe allergic reaction. The guidelines require parent/guardian request and a signed statement by the physician. The parent/guardian must also acknowledge immunity from liability to the District. CCSD form, Request to Authorize Student Self-Administration of Prescribed Medication for Asthma/Anaphylaxis (HS-96), is completed by the parent/guardian, physician and school nurse to meet this requirement. The form also authorizes administration by a trained staff member if the student is unable to do so. The school nurse will complete the Epinephrine Auto-injector Skills Checklist for students who are planning to self-administer injectable epinephrine, to determine if the student has the necessary skills to self-administer. Administration of Injectable Epinephrine by School Staff Member The Nevada State Board of Nursing Advisory Opinion permits trained unlicensed assistive personnel in schools to administer auto-injectable medication. The school nurse will delegate the administration of the epinephrine auto-injector to school staff members selected via consultation with the site administrator. The school nurse will perform all training and determine the competency of each staff member designated. Initial training and subsequent monthly refresher training will be documented on the School Nurse Verification of Training form (HS-123). 22

23 Stock Epinephrine (SB 453) Students with food allergies are entitled to Section 504 plans. Effective July 1, 2013, Nevada public schools are required to purchase and maintain a stock supply of auto-injectable epinephrine for pupil use on school premises during regular school hours. Each school site must have designated staff members trained to administer epinephrine via auto-injector in response to an anaphylactic emergency. Per Senate Bill 453, The school nurse coordinates with the principal of the school to designate employees of the school who are authorized to administer auto-injectable epinephrine. The school nurse provides the employees so designated with training in the proper storage and administration of auto-injectable epinephrine. Stock epinephrine auto-injectors will be maintained in a secure unlocked location for use when there is a reasonable belief that anaphylaxis is occurring in any pupil. In all instances 911 must be called when epinephrine has been administered. Use of injectable epinephrine necessitates transport of the pupil for emergency care. Section 504 Accommodation Plan Each CCSD school has a Section 504 Liaison, who is responsible for the oversight of Section 504 Plan development and monitoring. The Section 504 Liaison and site-based Section 504 Team will review all requests for development and implementation of a Section 504 Accommodation Plan, assess student, and determine if there is a qualifying disability under Federal law. If the student s disability qualifies him/her for a Section 504 Plan, the Team will proceed with development of the Plan, to ensure that appropriate supports and services to address the student s individual needs are provided. The CCSD Office of Compliance and Monitoring has determined that CCSD teams must consider a life-threatening allergy as a disabling condition. CCSD will provide 504 Accommodation Plans for students with food allergies and chemical sensitivities. The school nurse will participate on the Team for the preparation of the Section 504 Plan and will develop the Medical Alert as part of the Plan. The Plan will also include factors to address risk reduction, emergency response and any other additional precautions and accommodations needed by the student. It will include the period of time to and from school (if applicable), during the school day and during school sponsored activities. The Section 504 Accommodation Plan is reviewed annually or more frequently as needed. The Office of Compliance & Monitoring (OCM) has prepared training materials that include information regarding protections for students with food and other potentially life-threatening allergies. Please note: The Health Services Department maintains templates for all current HS Forms as well as current procedures. Student health information is maintained in the electronic documentation system Healthmaster (HMS). Templates are available to all school nurses via SHOMS. 23

24 School Nurse Guidelines The care and management of students with potentially life-threatening allergies at school is overseen by the school nurse. The school nurse will assist the school team in both prevention and emergency care of students with significant reactions. School nurses are encouraged to foster independence on the part of students, based on their developmental level. School nurses are asked to consider the following guidelines when planning for the safe school management of students with allergic reactions. School Nurse Checklist Schedule meeting with parent/guardian and teachers to discuss student s individual health concerns and development of Medical Alert. Gather appropriate health information regarding the allergy, including: 1) Identification of allergens. 2) Signs/symptoms of reaction. Note: previous response is not indicative of future responses, either by type or severity 3) Date of most recent reaction. 4) When parent/guardian first became aware of allergy. 5) Medication(s) ordered by licensed health care provider. 6) Medication required at school. 7) Special Diet order completed and submitted, if necessary. Students with individually prescribed on-site epinephrine injector: 1) Complete Epi-Pen Medical Alert (HS-65A). 2) Obtain orders from licensed health care provider (HS-166, Licensed Health Care Provider s Specialized Orders for Health Services at School: Anaphylaxis). 3) Collaborate with site administrator regarding delegation of epinephrine auto-injector administration to selected school personnel. There should be at least three (3) staff members identified and trained to administer epinephrine auto-injector. More staff members should be trained in middle and high schools with higher enrollments. 4) If parent/guardian requests student self-administration of epinephrine injection, request completion of Request to Authorize Self-Administration of Prescribed Medication for Asthma/Anaphylaxis (HS-96). 5) If completed HS-96 received, assess student s ability to self-administer auto-injector, using Epinephrine Auto-injector Skills Checklist (HS-241). 24

25 Students with no medication: Complete Anaphylaxis Medical Alert (No Medication) (HS-65C). Follow Stock-Epi-Pen protocol in the event of an anaphylactic episode. Develop 504 Plan with school 504 team to address student needs and accommodations, if appropriate. Disseminate Medical Alert and 504 Plan, to appropriate staff. Ensure epinephrine auto-injectors are stored in secure, unlocked, designated area(s). Ensure appropriate personnel are aware of location of medication and Medical Alert. Establish plan for notification of substitute personnel, including substitute school nurses, FASAs and teachers. Ensure all appropriate staff members receive individualized health and medication information on students with a history of potentially life-threatening allergic reactions. Establish a means of communication between playground/physical education staff and front office/health office staff. Assist in identification of allergy free eating area in cafeteria/classroom, as needed. Review transportation requirements/situation of student. Educate school staff regarding prevention, recognition and emergency response to potentially life-threatening allergic reactions. With parent/guardian permission, educate other students regarding a specific student s allergic reaction. Be alert for situations in which students with potentially life-threatening allergic reactions may be bullied, harassed, isolated, or stigmatized. Notify the site administrator and nurse coordinator as needed. For emergencies involving students with allergic reactions, provide appropriate medical information to Emergency Medical Services (EMS) personnel. Follow Field Trip Procedures 25

26 Field Trip Procedures Field Trip Checklist Students with no medication: Complete Anaphylaxis Medical Alert (No Medication) (HS-65C). Follow Stock-Epi-Pen protocol in the event of an anaphylactic episode. Discuss the field trip in advance with parent/guardian of a student at-risk for anaphylaxis. Invite parents of students at-risk for anaphylaxis to accompany their child on school trips, in addition to the chaperone(s). However, the parent s/guardian s presence at a field trip is NOT required. Identify the staff member who will be assigned the responsibility for monitoring the student s welfare and who will handle any emergency. These responsibilities include: Facilitating washing of hands before snack/lunch. Overseeing the cleaning of tables before eating. Ensuring the student with a food allergy only eats allergen-free foods or food supplied by the parent/guardian. Carrying a radio or communication device to be used in an emergency situation. Reviewing the student s Medical Alert or 504 Plan. Carrying and administering emergency medicine (antihistamine, epinephrine autoinjector) as outlined in Medical Alert (prior training required). Planning should be completed two weeks prior to field trip. Plan for an emergency situation (contacting 911 if needed and location of closest hospital). Follow school district policy for medication administration. All required medications, including over-the-counter medications, shall be given to the adult designated and trained by the school nurse. Consider how snack/lunch will be transported and stored and where food will be eaten while on the field trip. Ensure that all chaperones on the field trip are aware of students with food allergies. 26

27 Return to School Post-Reaction Checklist Return to School Post-Reaction Students who have experienced an allergic reaction may need special consideration upon their return to school. School staff should consider the severity of the reaction, the student s age and whether it occurred at school. A mild reaction may need little or no intervention beyond follow-up by the school nurse with the student and parent/guardian and review of the Medical Alert/504 Plan. If a student demonstrates anxiety about returning to school, reassurance may be needed regarding safety. The school nurse and/or other designated staff member should make contact with the student daily until the anxiety is resolved. If the student has a prolonged emotional response to the reaction, social and emotional support may be required. Return to School Post-Reaction Checklist The school nurse should obtain as much information as possible regarding the reaction. Helpful information might include: Cause of reaction; item(s) ingested or contacted (e.g., food, drink, medication, venom or other allergen) Date/time/location of reaction Symptoms which occurred Timing from contact/ingestion to onset of symptoms Type of medication administered Time of medication administration and response time Level of medical care required Persons witnessing reaction or involved with emergency response The school nurse should revise the Medical Alert/504 Plan, after a reaction has occurred. Consider additional training to appropriate school staff members if new information is received regarding student s allergy triggers, change in response, etc. If an allergic reaction is thought to be from a food provided by the District Food Service Department, request assistance of the Food Service Director to ascertain the potential food item served/consumed. 27

28 Preparing for an Emergency Preparing for an Emergency: School Nurse Emergency Response Checklist Provide training for school personnel about how to prevent, recognize, and respond to food allergy reactions. Identify team members for the emergency response team, including CPR/AED-trained personnel. Suggested Emergency Response Team Members: Administrative Staff Custodial Staff CPR/AED Trained Personnel School Nurse FASA Teachers Security PE Teachers Coaches Identify and train identified school staff in epinephrine administration. Create a list of volunteer delegates trained in the administration of an antihistamine and the epinephrine auto-injector. Disseminate the list appropriately. Ensure that an antihistamine and the epinephrine auto-injector are quickly and readily accessible by a member of the emergency response team in the event of an emergency. When available from parent/guardian, maintain a backup supply of the medication(s). Ensure that at least 2 doses of stock epinephrine are available at all sites and that replacement is completed prior to expiration. Provide monthly refresher training regarding epinephrine administration to all trained staff. Ensure that reliable radios or communication devices are available in the event of an emergency. Ensure access to an antihistamine, the epinephrine auto-injector, and allergy-free foods when developing plans for fire drills, lockdowns, etc. Coordinate with local Emergency Medical Service (EMS) on emergency response in the event of food-allergic reaction. Adhere to Occupational Safety and Health Administration (OSHA), CCSD procedures, and Universal Precautions Guidelines for disposal of epinephrine auto-injectors after use. No child should be left alone if an allergic reaction is in progress. In order for the child to receive appropriate care, the emergency response team needs to go to the location of the child having the reaction. Provide and review a copy of parent/guardian guidelines of students identified with potentially life-threatening allergies. Conduct an anaphylaxis emergency response drill at least yearly to establish response patterns. 28

29 School Administration Guidelines School Administration Checklist Collaborate with school nurse, parent/guardian and appropriate staff members to establish safe school management of students with potentially life-threatening allergies. Set a positive tone for food allergy management. Supervise and implement School Board Regulations and CCSD procedures for managing potentially life-threatening allergies in schools. Provide regular, on-going training and education for staff on policies and procedures for food allergies, including: How to recognize symptoms of an allergic reaction to foods, insect stings, medications, latex, etc. Review of high-risk areas. Steps to take to prevent exposure to allergens. How to respond to an emergency. How to administer an epinephrine auto-injector. Stock epinephrine procedures How to respond to a student with a known allergy as well as a student with a previously unknown allergy. Conduct and track attendance at required in-service training for staff at the beginning of the school year. The CCSD Procedures for Managing Students with Potentially Life-threatening Allergies in Schools, will be made available at each school. In collaboration with school nurse, conduct an anaphylaxis emergency response drill at least yearly to establish response patterns. Ensure all school personnel who supervise students with known food allergies are provided with the student s Medical Alert and 504 Plan (for example: teachers, specialists, bus driver, support staff such as SPTA s, lunchroom supervisors, etc.). Remind teachers to handle all matters relating to food and students with potentially lifethreatening allergies professionally and with sensitivity. Excluding foods, not students from the classroom will protect the safety of students and promote inclusive practices so that all children are provided a safe and respectful learning environment. Provide emergency communication devices (two-way radio, intercom, walkie-talkie, cell phone) for all school activities, including transportation, that involve a student with potentially lifethreatening allergies. Facilitate the acquisition of ingredient lists for food products and classroom products available in the school. Provide access to parent/guardian when requested. Recommend elimination of food products in the classroom. Encourage the use of non-food items for classroom activities. Outside vendors are not permitted to sell their products on campus from one-half hour before school starts until one-half hour after the end of the regular school day. All vending contracts must be reviewed and approved by district legal counsel prior to being signed by the school principal. (CCSD Concessions/Vending Site Contract dated 5/24/2012). The following school/classroom activities are exempt from the nutrition guidelines, but not from the prohibition of homemade food: 29

30 A. Suitable activities for: Halloween, Thanksgiving, Christmas and Valentine s Day. B. Schoolwide recognition parties are limited to NO more than four times each school year. C. Foods of minimal nutritional value cannot be given away or sold as part of these exempted activities (see Nutrition Standards 1D.) D. NO homemade food should be served to students from one-half hour before school starts until one-half hour after the end of the regular school day. The Food Allergy Research & Education organization supports the restrictions on homemade food due to the great threat of anaphylaxis when exposed to allergens. The School Nurses have worked to promote this policy within our Clark County School District. Food and beverage sold in administrative and faculty areas (must be accessible ONLY to adults and not accessible to students) are exempt from Nutrition and Beverage restrictions. All proceeds from the sale of approved food and beverages on school grounds must directly benefit school academics, activities or the CCSD Food Service Department. The Healthy Hunger Free Kids Act of 2010 provides for monitoring by the state agency and USDA that will require corrective action and assess monetary fines for those schools that do not comply with USDA Wellness Regulation, Nevada Department of Education Statewide School Wellness Policy and CCSD Nutrition and Beverage Standards. A school found to be noncompliant of this regulation by state or federal agencies will be liable for any and all fines assessed by said agency. Establish an allergen free table in the cafeteria and arrange for separate cleaning materials per guidelines provided by the Operations Department. Avoid selling any nut products or items manufactured in a facility that uses nuts or nut products in the student store and/or vending machines. Review Facility Use Permit (Regulation 3613) when outside groups (i.e. non-school-related organizations) use school property and food is present, to ensure that care is taken not to put students with food allergies at risk. Inform parent/guardian if any student experiences an allergic reaction for the first time at school. Suggest resources to parents. Recommend Medical Alert to parents. If parents are not cooperative, implement a Anaphylaxis Medical Alert (no medication) - HS 65-C, stating to immediately call 911 upon recognition of any symptoms and implement stock epinephrine procedures. Provide copy of HS-65C to parent/guardian. Include information about life-threatening food allergies in the student handbook/agenda to promote safety awareness, respect, and inclusion. Procedures for a Peanut-Safe School should include information such as the following: There are some students at our school who may have severe allergies to peanuts. At our school, we observe the following safety precautions to help our students who have potentially lifethreatening allergies stay safe: A. Our school works with the CCSD Food Services Department to ensure that peanutcontaining foods are not sold or served at our school. B. We have established a nut-free table in the cafeteria where students with nut allergies may eat safely with other students who observe the nut-free rule. 30

31 C. Strict consequences are given to students who throw food or who bully students with food allergies. D. We strongly encourage students to wash their hands after eating, especially if they have consumed food containing peanuts or peanut products. Students are reminded when washing their hands that they must use soap and water. Hand sanitizer does not work. E. Students with food allergies are strongly encouraged to carry their epi-pens with them. Include information regarding food-allergy related bullying in the deans orientation for students on behavioral expectations held at the beginning of the school year so students understand the disciplinary consequences of bullying, intimidation and harassment as well as the potential lifethreatening risk of bullying a student with a known allergy. Educate parents about potentially life-threatening allergies in schools by including information in parent newsletter, PAC meetings, and on school website to promote safety awareness and inclusion. Ensure the student s Medical Alert with photo ID, if available, is in the substitute teacher subfolders. The folder must include instructions for the substitute teacher to immediately contact the school nurse for education and instruction. 31

32 Parent/Guardian Guidelines (School Nurse to review with parent/guardian and provide them with a copy) Parents/Guardians are their children s first teachers. It is important for parents/guardians to ageappropriately educate their child with a food allergy as well as communicate information received from the child s doctors, etc. Preparing, role-playing and practicing procedures in advance will help everyone feel prepared in case of an emergency. Parent/Guardian of Children with Food Allergies Checklist Inform the school nurse of your child s allergies prior to the beginning of the school year (or as soon as possible after a diagnosis). Work with the school nurse to complete appropriate Medical Alert Assist the school nurse to obtain any required orders for self-administration and/or administration of medications for allergic response. Participate in team meetings and communicate with all staff members, including the school nurse who will be in contact with the child (preferably before the beginning of the school year,) to: Discuss evaluation of student, development and implementation of the Medical Alert and 504 Plan. Establish a prevention plan. Periodically (halfway through the year) review prevention and Medical Alert and 504 Plan with the team. Decide if additional antihistamine and epinephrine auto-injectors will be kept in the school, in addition to the one in the health office or designated area. Provide the school with up-to-date epinephrine auto-injectors. Replace auto-injector prior to expiration date. Submit a Medical Statement Request for a Special Diet to the Food Service Department. Consider providing shelf-stable, allergen-free snacks/lunches for your child. The snack/lunch will be available for your child for an unplanned special event or if the snack/lunch becomes cross-contaminated. Discuss location of allergen-free snack in classroom with student. Consider providing a medical alert bracelet for your child. Provide the school nurse with the licensed medical provider s statement if the student no longer has allergies. Attend your child s field trips or participate in class parties or events, if available (not required). Discuss emergency procedures for school district bus service with school personnel. Review transportation requirements/situation for student. Periodically teach your child to: Recognize the first symptoms of an allergic/anaphylactic reaction. 32

33 Know where the epinephrine auto-injector is kept and who has access to the epinephrine. Communicate clearly as soon as he/she feels a reaction is starting. Carry his/her own epinephrine auto-injector when developmentally appropriate and with physician order. Practice administering epinephrine using an epinephrine training device. Avoid sharing or trading snacks, lunches, or drinks. Understand the importance of hand-washing before and after eating. Report teasing, bullying, and threats to an adult authority. Request ingredient information for any food offered. If food is not labeled or if the child is unsure of the ingredients, the child should politely decline the food being offered. 33

34 Student Guidelines The student with food or other life-threatening allergies is the most important member of the safety team. The student should be able to identify his/her food or other allergies, as soon as it s developmentally appropriate. It is important to make the student aware of what accommodations he/she is or should be receiving so that he/she might assist appropriately. Students with Food or other Potentially Life-threatening Allergies Checklist Recognize the first symptoms of an allergic/anaphylactic reaction. Know where the epinephrine auto-injector is kept and who has access to the epinephrine autoinjector(s). Inform an adult as soon as accidental exposure occurs or symptoms appear. Carry own epinephrine auto-injector when appropriate. Self-administer epinephrine, if capable, during reaction. Avoid sharing or trading snacks, lunches, or drinks. Wash hands before and after eating. Report teasing, bullying, and threats to an adult authority. Ask about ingredients for all food offered. If unsure that the food is allergen-free, say no thank you and do NOT take or eat the food. Learn to become a self-advocate as you get older (refer to parent/guardian guidelines on previous page). Develop a relationship with the school nurse or another trusted adult in the school to assist in identifying issues related to the management of the allergy in school. Every single person plays an important role in preventing food-allergic reactions, including the child with the food allergies. 34

35 Classroom Teacher/Specialist Guidelines (School Nurse to review with teachers and provide a copy) Teachers are ultimately the student s first line of defense. Teachers are asked to assist the school team in the care and management of students with food allergies, as well as the prevention and treatment of allergic reactions. The following guidelines should be reviewed, followed, and enforced by teachers and others entering the classroom. Classroom Teacher/Specialist Checklist Surface cleaning wipes or hand sanitizer are not a substitute for hand washing. Use soap and water for hand washing. Do not question or hesitate to immediately initiate plans in a Medical Alert if a student reports symptoms or exhibits signs of an allergic reaction. Maintain a copy of the student s Medical Alert and 504 Plan in the classroom and ensure it is accessible. Seek assistance if student has ingested, or is suspected to have ingested, a known allergen. Ensure students with suspected allergic reactions are accompanied by an adult at all times. Initiate emergency response team if allergic reaction is suspected. Wash hands before and after eating. Participate in any team meetings for the student with food allergies, in-service training, or a meeting for a student s re-entry after a reaction. Allow the student with food or other life-threatening allergies to maintain the same locker and desk all year to help prevent accidental contamination, since food is often stored in lockers and desks. Consider providing storage for lunches and other food products outside the classroom. Wipe computer keyboards, musical instruments and other equipment used with a school district-approved cleaner for student or provide separate items as called for in Medical Alert or 504 Plan. Establish a means of communication in the school to permit swift response. Adapt curriculum, awards, rewards, or prizes by substituting non-food items in rooms where students with potentially life-threatening food allergy may be present. Parents may be helpful in identifying safe alternatives or providing other recommendations. Many schools have recommended completely removing food from the curriculum due to the number of students with food allergies and the variety of food allergies present within a school or classroom (Constructive Classroom Rewards Appendix C). Awards/Rewards/Pizza and Ice Cream Parties students with dairy allergies cannot participate and require accommodations with safe food in order to participate. Older students often do not want attention focused on them due to the need for special foods and/or other accommodations. When possible, select non-food celebrations or select a variety of safe foods. Provide current information for substitute teachers in an organized, prominent, and accessible format. Follow school district guidelines for substitute teacher folders. Ensure student s medical alert and photo ID is in the folder. 35

36 Inform parent/guardian of the student with potentially life-threatening allergies at least two weeks in advance of any in-class events where food will be served or used. Provide ingredient lists for food products and classroom products available in the school to parent/guardian when requested. Avoid endangering, isolating, stigmatizing or harassing students with food allergies. Be aware of how the student is being treated, and enforce school rules about bullying and threats (Appendix A). Do not send students with potentially life-threatening allergies home on the bus if they report any symptoms of an allergic reaction, no matter how minor. Classroom Activities Checklist Ensure that food or products containing the student s allergens are not used for class projects, parties, holidays, and celebrations, arts, crafts, science experiments, cooking, snacks, or other purposes. Avoid the use of food in classroom activities/projects. Encourage students to bring healthy snacks like fruits and vegetables if snacks are required. Avoid isolating or excluding a student because of allergies (e.g., using candy or other food items as part of a lesson). Limit food related to fundraising or PTA functions to designated areas. All food and beverages sold or given away must meet the CCSD Nutrition and Beverage Standards. Consider substitution of non-food items (Constructive Classroom Rewards Appendix C). For birthday parties, consider a once-a-month celebration in the multi-purpose room with non-food items or approved foods that meet the CCSD Nutrition and Beverage Standards. Pay special attention to other allergies students may have, such as potentially life-threatening allergies to animals. Follow CCSD guidelines in regard to pets/animals in the school setting. Cleaning of computer keyboards should also be addressed for the protection of students with potentially severe allergic reactions to foods such as nuts, as the keyboards could be contaminated by students eating those substances who did not properly wash their hands after eating. This should be addressed individually at the school site for those students with potentially severe allergic reactions. Possible plans include keyboard covers, designated allergy free keyboards, or other approaches to ensure that keyboards have been cleaned. Hand-washing by students prior to use of computers should be encouraged. 36

37 Classroom Snack Checklist Restrict allergens from the classroom of a student with potentially life-threatening allergies at all times. If classrooms are used for meals in schools, there must be a designated allergen-free area. A designated time slot for food consumption in the classroom should be established. Steps must be taken so that these areas are not contaminated by allergens. Avoid use of classroom for meals whenever possible. Ask (do not require) the parent/guardian of a student with food allergies to provide allergenfree snacks for his/her own child. These snacks should be kept in a separate snack box or chest. Encourage healthy snacks such as fruits and vegetables. Do not allow a student who inadvertently brings a restricted food to the classroom, to eat that snack in the classroom. This student will have to eat the restricted food in the designated area or take the snack home Prohibit the sharing or trading food at school. Avoid sharing or trading of utensils. Wash tables with school district-approved cleaning agents before and after snack, with special attention given to designated allergen-free eating areas. Use separate cleaning equipment for allergen-safe tables. Wipe down the student s area or individual desk or adjoining desks if contamination of foods is suspected. An adult/teacher/designated school personnel must wipe the area. The student must not be required to wipe down his/her own area prior to eating to avoid accidental exposure to or ingestion of allergens. Utilize District approved cleaning agents. Teach students proper hand washing technique. Hand washing should be required before and after the handling/consumption of food. All persons entering the classroom are encouraged to wash/wipe hands upon entering. Hold before and after-school events that include food in the cafeteria/gym or a pre-approved designated food area. 37

38 Field Trip Checklist Choose field trips carefully to ensure that students with potentially life-threatening allergies have little or no allergen exposure. Review the Medical Alert and 504 Plan. Provide two weeks advance notice of field trips to the school nurse and parent/guardian. Provide a list of students who will participate in the field trip to the school nurse. The nurse will provide information to the responsible CCSD teachers regarding students medical conditions including food allergies. Consider the presence/handling of any food item while on the field trip. Be aware that additional chaperones may be required when a student with potentially lifethreatening allergy is present. Student(s) experiencing a reaction must be accompanied by an adult at all times. A designated adult from the school staff should follow the ambulance when a student is being transported by EMS when the parent/guardian is not present. Discuss the field trip in advance with parent/guardian of a student at-risk for anaphylaxis. Invite parents of students at-risk for anaphylaxis to accompany their child on school trips, in addition to the chaperone(s). However, the parent s/guardian s presence at a field trip is NOT required. Consider how snack/lunch will be transported and stored and where food will be eaten while on the field trip. Field Trip Medication Checklist Notify the school nurse of any field trip at least two weeks in advance. Acquiring the medications, Medical Alerts, and communication device the morning of the trip is the school personnel s responsibility. School district policy for dispensing medicine should be followed. Provide the trained adult who is to administer the medication with the Medical Alert, instructions about the medications and all required medications, including over-the-counter medications ordered by the licensed health care provider. Medications deemed rescue drugs such as epinephrine auto-injector(s) and asthma inhaler(s) may be self-carried/administered by the student, if written authorization is on file. An adult trained in the administration of these medications must also be available in case the student is not able to self-administer. Review Medical Alert. Provide medication in a labeled container with the date and time that it is to be given. Emergency or rescue medication must be labeled appropriately. 38

39 Food Service Guidelines Schools must provide a meal substitution if it is required by a physician s order or if the school participates in a federally-funded child nutrition program and the student has a disability that restricts their diet as documented by a licensed health care provider. A Medical Statement Request for a Special Diet should be submitted to the Food Service Department so they may provide the proper nourishment for students requiring special diets. Parents and students should be allowed access to food labels to identify ingredients in the products used by the school s cafeteria. According to a United States Department of Agriculture Food and Nutrition Service publication, Accommodating Children with Special Dietary Needs in the School Nutrition Programs : The school has the responsibility to provide a safe, non-allergic meal to the student if it is determined that the condition is disabling. To do so, school food service staff must make sure that all food items offered to the allergic student meet prescribed guidelines and are free of foods which are suspected of causing the allergic reaction. This means that the food labels or specifications will need to be checked to ensure that they do not contain traces of such substances. In some cases, the labels will provide enough information to make a reasonable judgment possible. If they do not provide enough information, it is the responsibility of the school food service personnel to obtain the necessary information to ensure that no allergic substances are present in the foods served. In some cases, it may be necessary to contact the supplier or the manufacturer or to check with the State agency. Private organizations may also be consulted for information and advice. It is also wise to check with parents about certain foods and even provide them with advance copies of menus. The general rule in these situations is to exercise caution at all times. Do not serve foods to students at risk for anaphylactic reactions, if you do not know what is in those foods. It is important to recognize that a student may be provided a meal, which is equivalent to the meal served to other students, but not necessarily the same meal. (United States Department of Agriculture Food and Nutrition Service, Accommodating Children with Special Dietary Needs in the School Nutrition Programs, Fall 2001) 39

40 CCSD Food Service Form for Modifying Meal SPECIAL DIET REQUEST POLICIES This guidance is based on the policy guidelines outlined in the Food and Nutrition Services Instruction 783-2, Revision 2, Meal Substitutions for Medical or Other Special Dietary Reasons. Under Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990, a person with a disability means any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such impairment. An IEP (Individualized Education Program) must be completed. An IEP is a written statement for a child with a disability that is developed, reviewed, and revised in accordance with the IDEA (Individuals with Disabilities Education Act) and its implementing regulations. The IEP is the cornerstone of the student s educational program that contains the program of special education and related services to be provided to a child with a disability covered under the IDEA. USDA regulations 7CFR Part 15b require substitutions or modifications in school meals for children whose disabilities restrict their diets. A child with a disability must be provided substitutions in foods when that need is supported by a statement signed by a licensed physician. The Physician s statement must identify: The child s disability An explanation of why the disability restricts the child s diet The major life activity affected by the disability The food or foods to be omitted from the child s diet, and the food or choice of foods that must be substituted, including changes in food texture Children with food allergies or intolerances may have a disability as defined under either Section 504 of the Rehabilitation Act or Part B of IDEA, and the school food service may, but is not required to, make food substitutions for them. When a licensed physician s assessment states food allergies may result in severe, life-threatening (anaphylactic) reactions, the child s condition would meet the definition of disability, and the substitutions prescribed by the licensed physician must be made. When a child with disabilities requires a change in a diet order, the parent must provide documentation with accompanying instructions from a licensed physician. This is required to ensure that the modified meal is reimbursable, and to ensure that any meal modifications meet nutrition standards which are medically appropriate for the child. PROCEDURES 1. Assess student 2. Complete IEP, if required 3. Obtain physician s statement 4. Submit to CCSD Food Service Department 5. If any changes in diet are required, submit a revised physician s statement. FSD-F150, Rev. C August 3,

41 CLARK COUNTY SCHOOL DISTRICT 6350 E. Tropical Parkway, Las Vegas, NV MEDICAL STATEMENT TO REQUEST A SPECIAL DIET Parent/Guardian: Complete Items 1-6 (Pader/tutor: Compleata cajitas 1-6) 1) Student s Last Name (Apellido) 4) Parent/Guardian Signature (Firma del Padres/Tutor) First Name (Nombre del estudiante) 2) Date of Birth (Fecha de nacimiento) 5) Print Name of Parent (Escriba en letra de molde el nobre del padres) 3) Circle Meals Eaten at School (Circule las comidas que su nino/a come en la escuela) Breakfast Lunch Snack (Desayuno) (Amuerzo) (Bocadillo) 6) Parent Phone Number(s) (Numero(s) de telefono del padres Home (Casa): ( ) Cell (Celular): ( ) School Nurse: Complete Items ) School Name 8) Year Round School: Yes No 9) School Nurse 10) School Nurse s Phone # 11) School Fax # PHYSICIAN ONLY: Complete Items ) Does the student have a disability, medical condition or severe food allergy warranting a special diet? The disability or medical condition must limit a major life activity such as breathing or learning, and the food allergy can result in a reaction that is life-threatening and/or severely impacts the student s ability to function in school. YES If YES, continue to complete the remainder of this form. NO If NO, STOP HERE. A SPECIAL DIET IS NOT WARRANTED. 13) Disability, Medical Condition, or Severe Food Allergy: 14) Severe and/or Life-threatening Reaction: 15) Major Life Activity Affected by Child s Disability: Breathing Eating Other 16) Diet Order: 17) Texture Modification: If needed, circle one appropriate for the student: CHOPPED GROUND PUREED 18) Physician s Signature 19) Physician s Printed Name 20) Telephone Number 21) Date 22) Name & Phone of Registered Dietitian Following Student: Please notify in writing any changes in school (including transitioning from elementary to middle to high school) two (2) weeks prior to any change. Any diet order changes (including texture) require a signed diet order. 41

42 Food Service Checklist - Cafeteria Personnel, Student Workers Review the school district Food Allergy Policy and Procedures and direct any questions to the school nurse or Food Services Department. Follow school district policy regarding the dissemination of information relative to food allergies. Implement all recommendations and requirements for students with an IEP or 504 Plan (when indicated). Take all complaints seriously from any student with a life-threatening allergy. Establish procedures for the cafeteria regarding students with food allergies. Review menus (breakfast, lunch, and after-school snack), a la carte items, vending machines, recipes, food products, and ingredients to identify potential allergens. Meet with parent/guardian to discuss student s allergy, if requested. Make available copies of the menu or menu changes to parent/guardian when requested. Make appropriate substitutions or modifications for meals served to students with food allergies after receiving a completed Physician s Medical Statement Request for a Special Diet. Special Diets will be prepared in the Central Kitchen facility. Provide allergen-free meals for field trips, if requested. Identify food handling practices, cleaning, and sanitation practices, and the responsibilities of various staff members to prevent cross-contamination. Provide training for all food service personnel about cross-contamination as part of the school s federally required food safety plan. Maintain a nut-free Central Kitchen. Avoid the use of latex gloves by food service personnel. Instead order non-latex gloves for food service personnel. Read all food labels and re-check routinely for potential food allergens. Check each time a food order is received since ingredients can change without notice. Train all food service staff to read product food labels and recognize food allergens. Maintain contact information for manufacturers of food products. Maintain food labels from each food served to a student with allergies for at least 24 hours following service, in case the student has a reaction from a food eaten in the cafeteria. Sign up for notification of recalls from the Food Allergy Research & Education, Inc. and the FDA. 42

43 Cafeteria Checklist Monitors and Custodial Staff Cafeteria Guidelines Create specific areas that will be allergen safe. Establish Be A PAL (Protect A Life) Allergy Aware cafeteria tables. Designated eating areas will be provided where students feel safe to eat, but are not excluded. Provide allergen-free table(s) (i.e., students not eating peanut butter/nuts can sit together). Maintain a functioning communication system in place to support emergencies. Clean tables and chairs routinely after each sitting with school district-approved cleaning agents, with special attention given to designated allergen-free eating areas. Minimize the risk of cross-contamination between the allergen-free areas and other cafeteria/ MPR tables by using a separate bucket, supplies and fresh water when cleaning the allergy-free area. Use separate cloths for allergen safe tables. It is suggested that cloths and buckets be color-coded for easy identification of those designated for allergen-free eating areas. Participate in all in-service training regarding the identification of food-allergic reactions, riskreduction, and emergency response procedures. Take all complaints seriously from any student with a life-threatening allergy. Immediately advise school nurse, FASA, or attending staff member of situation. 43

44 Operations/Custodial Staff Guidelines Custodial Staff Checklist Students with potentially life-threatening allergies require a safe environment while at school. All custodial staff must receive training regarding the guidelines for cleaning and maintaining a safe school environment and supporting students with potentially life threatening allergies at school. These guidelines must be followed consistently. Review the school district Food Allergy Policy and Procedures and direct any questions to Operations Department Custodial Supervisor or school nurse. Participate in all in-service training on the identification of food-allergic reactions, riskreduction, and emergency response procedures. Take all complaints seriously from any student with a life-threatening allergy. Immediately advise school nurse or attending staff member of situation. Clean cafeteria tables, chairs, and floors routinely after each sitting following CCSD Operations Department Cafeteria Table Sanitizing Procedures. Utilize only school district-approved cleaning agents, with special attention given to designated allergen-free eating areas. Use separate cleaning equipment for allergen safe tables. Clean classrooms, desks, doorknobs, and lockers routinely with school district-approved cleaning agents, with special attention to classrooms attended by students with food allergies. The Medical Alert and 504 Plan may direct the frequency of cleaning. Note: Cleaning of computer keyboards should also be addressed for the protection of students with potentially severe allergic reactions to foods such as nuts, as the keyboards could be contaminated by students eating those substances who did not properly wash their hands after eating. This should be addressed individually at the school site for those students with potentially severe allergic reactions. Possible plans include keyboard covers, designated allergy free keyboards, or other approaches to ensure that keyboards have been cleaned. Hand-washing by students prior to use of computers should be encouraged. Alert site administrator and/or Operations Supervisor regarding any assistance needed to maintain consistency with guidelines. 44

45 CLARK COUNTY SCHOOL DISTRICT OPERATIONS DEPARTMENT VERIFICATION OF TRAINING Employee Name: Loc. #: Location Name: Date of Training: Reason For Training: Procedure for Cafeteria Table Sanitizing I, (please print), have received and understand the training in the areas listed below. As an employee of the Clark County School District Operations Department, I understand that it is my responsibility to keep up to date on any new products and procedures by reviewing Material Safety Data Sheet information and attending additional training sessions provided by the Operations Department Training Section. Attached Documents: Clark County School District Operations Department Cafeteria Table Sanitizing Procedures Cafeteria Table Cleaning Procedures, Essential Elements Cafeteria Sanitizing Procedures, Equipment and Items Needed to Complete Procedure Cafeteria Table Sanitizing Procedure Flow Chart Sanitizer Log Catalog Item Order Numbers Material Safety Data Sheet Employee Signature Date: Trainer s Signature: Date: Ops-Rev. B October 29, 2012 Pg. 1 45

46 SANITIZING BETWEEN LUNCHES CLARK COUNTY SCHOOL DISTRICT OPERATIONS DEPARTMENT CAFETERIA TABLE SANITIZING PROCEDURES If there are large food spills, wipe them with a damp towel. 1. Prepare sanitation bucket with three gallons of water and CorrectPac 1603 Sanitizer Solution. 2. Dip & wring green and white flat mop in sanitizer solution. 3. Mop all flat cafeteria table surfaces. 4. Allow all cafeteria tables to air dry. 5. Check the water with Sanitizer Test Strips. Immerse test strips in still solution for 10 seconds between lunches to ensure the sanitizer solution in the bucket is 200 ppm (parts per million). Be sure to log each reading on Sanitizer Log. 6. If reading is below 200 ppm, rinse bucket and flat mop and prepare new solution. CLEANING AFTER LUNCHES If there are large food spills, wipe them with a damp towel. WASH I. Dump Sanitizer. Rinse bucket and flat mop 2. Prepare sanitation bucket with two gallons of water and ScrubPac 102 All Purpose Cleaner. 3. Use the green and white flat mop to wash all cafeteria table tops. 4. Dip and wring as needed. 5. Dump ScrubPac I 02 solution. Rinse bucket and flat mop. RINSE 1. Prepare sanitation bucket with two gallons of clear water. 2. Rinse all cafeteria table surfaces with clear water using green and white flat mop. 3. Dip and wring as needed to maintain clean mop head. 4. Dump water. Rinse bucket and flat mop. SANITIZE 1. Prepare sanitation bucket with three gallons of water and CorrectPac 1603 Sanitizer Solution. 2. Dip & wring green and white flat mop in sanitizer solution. 3. Mop all flat cafeteria table surfaces. 4. Dip and wring as needed. 5. Dump Sanitizer. Rinse bucket and flat mop and put away. 6. Allow all tables to air dry. ALLERGEN FREE ZONE Custodians have a key role in ensuring cafeteria tables are cleaned and sanitized properly to remove food allergens. To prevent cross contamination, you will need to provide a separate table sanitizing kit labeled as Allergen Free Table only. Please encourage your site administrator to have a separate allergen free table with labels. Ops Rev. B October 29, 2013 pg. 2 46

47 CLARK COUNTY SCHOOL DISTRICT OPERATIONS DEPARTMENT Cafeteria Table Sanitizing Items and Order Numbers ITEM NUMBER ITEM DESCRIPTION PRICE 70 KIT Kit Sanitizing Table Complete $ Each Sanitizing Packs Table Top $59.50 Box MA8206 Bucket Combination Table Sanitizing $94.74 Each ME0240 Handle 2 ft. for Table Top Sanitizing $7.74 Each MK4000 Microfiber for Table Sanitizing (Green) $7.75 Each MA4003 Holder Mop Microfiber for Table $21.20 Each CG1500 Strips Test For Quaternary Levels Ops Rev. B October 29, 2013 pg. 3 47

48 Cafeteria Sanitizing Procedure 48

49 Cafeteria Sanitizing Procedure 49

50 Outside-of-Classroom Activities Guidelines Students participate in many activities outside the classroom. It is critical that students with potentially lifethreatening allergies be provided a safe environment both inside and outside the classroom. These activities might include recess, physical education, field trips, school-sponsored events, or athletics. Teachers and staff responsible for lunch, recess, coaching, or non-classroom activities must be trained to recognize and respond to a severe allergic reaction. Other Instructional Areas/Lunch/Recess Monitors Checklist Train adult supervisors responsible for students with food and other potential life-threatening allergies. Take all complaints seriously from any student with a life-threatening allergy by immediately initiating plans in their Medical Alert. Accompany students with suspected allergic reactions. An adult must be with the student at all times. Students experiencing an allergic reaction must not be left alone. Ensure current antihistamine and epinephrine auto-injector (personal or stock epinephrine) is readily accessible to students with life-threatening allergies. An adult staff member, trained in its use, must be-onsite. Follow CCSD Stock Epinephrine Procedures. Establish a means of emergency communication (2 way radio/cell phone/similar communication device) by staff in the gym, on the playground, and other recess sites. Reinforce that only students with allergen-free lunches or snacks eat at the allergen-free table. Encourage hand washing or use of hand wipes for students after eating. Utilize latex-free gloves and products for student with latex allergies and use caution in planning outside activities. Minimize outside activities in areas known to have current bee activity as a proactive measure to avoid potential life-threatening bee stings. Respond to exercise-induced allergic symptoms, as well as allergic symptoms caused by other allergens according to a Medical Alert and 504 Plan. 50

51 Outside-of-Classroom Activities Guidelines Athletics Coaches/Activity Leaders/Athletic Trainers Checklist Provide school coaches or other program adults with specific information pertaining to all known students with potentially life-threatening allergies, with parent/guardian permission. Review the Medical Alert and 504 Plan with school nurse. Identify who is responsible for maintaining epinephrine auto-injector(s) during sporting events or activities. Ensure a current epinephrine auto-injector is readily accessible for students with potentially life-threatening allergies. An adult staff member, trained in its use, must be available on-site. Follow CCSD Stock Epinephrine Procedures. Make certain that an emergency communication device (i.e. 2-way radios, intercom, cell phone, etc.) is always available. Ensure that before-and-after school activities sponsored by the school comply with school policies and procedures regarding potentially life-threatening allergies. Follow the field trip checklist, and transportation checklist. Avoid the presence of allergenic foods at activity sites and consider eliminating the use of allergenic foods in activities. 51

52 Transportation Department: Guideline for Health Care Plan/Medical Alert Major Area for Concern: Severe Allergy and Other Life Threatening Medical Conditions Alerts Rules Description: Transportation Guide, Student Care Plan & Medical Alert Submittal Process Focus Area: Student Reaction to Allergens, Medical Alerts & Driver Awareness Consequences: Potential for Anaphylactic Shock & Potential Loss of Life Due to Other Life Threatening Conditions CCSD Procedural Changes: Training Enhancement, Care Plan/Medical Alert Guidelines, Driver/Aide Instructions Prepared By Document Owner(s) Doug Geller Therese Barnhill Nathaniel Whitney Cynthia Koziol Shannon Evans Paul Shelley Marcelo Valenzuela Project/Organization Role Transportation Dept./ Director I Trans. Dept./ SS Training Supervisor Trans. Dept./ Coordinator IV, ESE Trans. Dept/Registered Nurse Trans. Dept./ Coordinator IV, R&S/Training Trans. Dept./ Coordinator IV, Gen Ed. Trans. Operations Manager Project Charter Version Control Version Date Author Change Description V1 12/10/12 Doug Geller Document created V1.1 04/17/13 Doug Geller Document finalized V1.2 11/7/13 Doug Geller, Shannon Evans, Cynthia Koziol, Therese Barnhill, Marcelo Valenzuela Document Updated 52

53 Transportation Guideline: Transporting Students with Health Care Plan/Medical Alert All students with potentially life-threatening medical conditions including but not limited to diabetes, asthma, seizures, and severe allergies require a safe environment while being transported to and from school. In collaboration with Health Services, other instruction and related service providers and parent advocacy groups; processes have been developed to protect these students, improve their environment and prepare to react immediately, should any reaction to an allergen begin to affect a student. The following provides guidelines and explanation regarding distribution of care plan/medical alert, cleaning requirements, avoiding allergen exposure, employee training and timely response to medical alerts and emergencies. Provide school bus drivers/bus aides with training in risk reduction procedures, recognition of emergency medical conditions including allergic reactions, with specific implementation of the Transportation Department emergency procedures. Bus drivers and aides will complete the mandatory Anaphylaxis Training on Pathlore at the beginning of each year. Pathlore will register the training and successful completion of the course. School Nurses will submit care plans/medical alerts to the transportation department for students riding the school bus that have known life threatening medical conditions including those with severe allergies. Health Care Plan/Medical Alert information will be attached and secured as part of the student s transportation record, noted on the route tiering, and explained in the run/stop notes. Drivers and bus aides will be given a care plan/medical alert for every student with known lifethreatening allergies or medical alerts including but not limited to diabetes, seizures, and asthma. Close attention should be given to the description of the student s medical condition and know the signs and symptoms to observe, and immediate emergency actions to take. Some of the signs and symptoms of a life threatening medical condition include, but are not limited to: difficulty breathing, wheezing, coughing, shortness of breath, pale or blue coloring of face and lips, difficulty swallowing, swelling of the tongue or lips, and or eyes, hives, rashes, vomiting, abdominal pain, dizziness, confusion, seizure activity, fainting, and/or loss of consciousness. Driver/Aide should place the Health Care Plan/Medical Alert in the confidential or continuity folder for the student s assigned Route(s). Remember that the health care plan/alert contains confidential and legally privileged information that is intended only for the purpose of providing the student with safe transportation to and from school. Any questions or concerns regarding the required driver/aide observation and emergency action to be taken should be discussed immediately with the appropriate Transportation Operations Assistant (TOA), Transportation Operations Manager (TOM), or site administrator. 53

54 Students with severe allergic reactions should be offered assigned seating within the first three (3) rows so that the driver can observe the student for any potential allergic reactions. Student/guardian has the right to refuse special seating arrangements. Driver/aide should be careful not to single out the student. Some students may have an EpiPen prescribed, if available, the EpiPen should be carried on the bus; preferably in the student s backpack. Health Care Plan/Medical Alert information will be attached and secured as part of the student s transportation record, noted on the route tiering, and explained in the run/stop notes. Bus drivers/aides may assist a student with self-administration of a medication/procedure by assisting the student in locating the device/medication in a backpack/purse. All students who carry medications on their person in the bus must be deemed independent in the delivery of such medications with the exception of EPI pens and asthma inhalers. The school nurse will determine which students are independent in self-administration of medications following CCSD Health Services Policies Bus drivers/aides may NOT administer a medication or perform a procedure unless they have been trained by the site school nurse for that student. In the event that a student goes into cardiac arrest or stops breathing, begin Cardio Pulmonary Resuscitation (CPR). If needed, verbal instructions can be provided by the 911 operator. Bus drivers/aides will initiate emergency procedures for students experiencing severe allergic reactions or medical emergencies which include contacting Dispatcher to call 911 immediately and speaking with the student about any known medical issues. A student with a suspected allergic reaction or medical emergency, already in progress, must not board the bus. Maintain policy of no food consumption allowed on school buses, unless medically necessary such as in the case of a diabetic student. Do not leave a student having a suspected allergic reaction or any medical emergency alone. Call Transportation Dispatch for any emergency. A copy of all health plans/medical alerts will also be kept in the front office and are made available to substitute/extra board bus drivers and aides. Substitute/extra board drivers will be required to go to the TOA office before beginning a shift to pick up/review the confidential or continuity folder containing Student Health Care Plans/Medical Alerts.. Ensure functioning emergency communication device (e.g., cell phone or two-way radio) is available. Ensure careful cleaning of bus surfaces, including seats and handrails. Reference the student s care plan/medical alert for appropriate treatment during an emergency. Use universal precautions when warranted by wearing latex free gloves. 54

55 Transportation Notification: Health Care Plans and Medical Alerts for Bus Riders Notification Many students within the school district may require additional care, supervision, equipment and/or services to meet their needs as per a Health Care Plan or Medical Alert. It is important that when these students also utilize transportation services that the Bus Driver be informed of the students Care Plan and/ or Medical Alert. Communication The most efficient way to provide information to the Transportation Department is electronically. This ensures the confidentiality, storage, and communication of the information. Once the Health Care Plan/ Medical Alert are received, the documentation can be attached to the students transportation record and forwarded/printed for distribution to the assigned driver(s)/aide(s) and Operations Manager/Assistant. Routing staff will make the necessary notations in the student s record, route tiering, and stop/run notes. As students transition from school to school, the Care Plan or Medical Alert will remain part of the student s transportation record. Upon receipt of the care plan/medical alert, the driver/aide will also receive the department s instructions as it pertains to students with severe allergies, asthma, seizures, and/or diabetes. The driver/aide is expected to comply with both the plan/alert and department direction. Submittal Process Once the School Nurse writes a Health Care Plan and/or Medical Alert for a student that also rides the school bus, they will need to do one of the following: 1 - Attach the document (with the student s District ID number) to an via InterAct and send to TRANSP-1 Requests R/S Department. Indicate Health Care Plan as the subject or; 2 - Fax the document (with the student s District ID number) to Although the document is faxed, it will be delivered into the InterAct in-box. The designated transportation employee(s) will move the document from the and follow the communication process above. 55

56 PROJECT EXECUTIVE SUMMARY Given the known risk factors for students with severe allergies, it is essential that Drivers be informed whenever a student with severe allergies may be assigned to their bus. Drivers must be trained in these processes and be prepared to respond appropriately and in a timely manner. Attachments: 1 - Driver/Aide Expectations and Responsibilities 2 Driver/Aide Training Checklist 56

57 Training Checklist for Bus Drivers and Bus Aides Medical Emergencies Including Severe Allergic Reactions The following is to be covered and verified by the Bus Driver/Aide Classroom Instructor as part of new employee training. Yes/No Explanation of Subject Bus Drivers and Aides will complete mandatory on-line Pathlore Training each school year: HRMAND 1310 Anaphylaxis Orientation for new bus drivers and aides (beginning January 1, 2014) will include the American Heart First Aid Video which covers most medical emergencies including asthma, seizures, diabetes, and severe allergies Bus Drivers and Aides will review transportation guidelines: Transporting Students with Health Care Plan/Medical Alert Discuss the no food policy on bus with the exception of diabetes. Discuss common symptoms of medical emergencies including, but not limited to, difficulty in breathing (wheezing, coughing, shortness of breath), pale, blue coloring of face and lips, difficulty swallowing, swelling of tongue and/or lips, and eyes, hives, rashes, vomiting, abdominal pain, dizziness, confusion, fainting, loss of consciousness. Review student confidentiality requirements Discuss and review Bullying Awareness and reporting Encourage hand washing or use of hand wipes for students after eating. Explain that the school nurse at each school will determine the necessity of training specific bus drivers and/or aides on the need for specific procedures on identified students including the administration of an EpiPen, application of VNS Magnet, and oral suctioning per CCSD Health Services Policies. The bus driver/aide must meet with the school nurse at the school of the identified student(s) once per month for verification of training. Review process in which bus drivers/aides may assist a student with self-administration of a medication/procedure by assisting the student in locating the device/medication in a backpack/purse. All students who carry medications on their person in the bus must be deemed independent in the delivery of such medications. The school nurse will determine which students are independent in selfadministration of medications following CCSD Health Services Policies Explain that bus drivers/aides may NOT administer a medication or perform a procedure unless they have been trained by the site school nurse for that student. Review the Driver/Aide Expectations and Responsibilities checklist upon distribution of a Health Care Plan/Medical Alert to the driver and/or aide In the event that a student goes into cardiac arrest or stops breathing, begin Cardio Pulmonary Resuscitation (CPR). If needed, verbal instructions can be provided by the 911 operator. Training Class Date: Classroom Instructor: Class Type (circle one): Bus Driver Bus Aide 57

58 Student Health Care Plan/Medical Alert Driver/Aide Expectations and Responsibilities Drivers and Aides receiving these instructions and check list have one or more students assigned to their route with a Health Care Plan or Medical Alert. This information will help ensure that you are prepared to respond appropriately in the event of an emergency. Students with known allergies and other life threatening medical conditions such as asthma, seizures, and diabetes may require additional driver awareness, training and/or supervision. The following instructions and checklist will help ensure that you understand your responsibilities and expectation Initial to Indicate Expectation/Responsibility Understanding Review the Health Care Plan/Medical Alert document thoroughly. Pay close attention to the description of the student s medical condition and know the signs and symptoms to observe, and immediate emergency actions to take. Some of the signs and symptoms of a life threatening medical condition include, but are not limited to: difficulty breathing, wheezing, coughing, shortness of breath, pale or blue coloring of face and lips, difficulty swallowing, swelling of the tongue or lips, and or eyes, hives, rashes, vomiting, abdominal pain, dizziness, confusion, seizure activity, fainting, and/or loss of consciousness. Any questions or concerns regarding the required driver/aide observation and emergency action to be taken should be discussed immediately with the appropriate Transportation Operations Assistant (TOA), Transportation Operations Manager (TOM), or site administrator. Place the Health Care Plan/Medical Alert in the confidential or continuity folder for the student s assigned Route(s). Remember that the health care plan/alert contains confidential and legally privileged information that is intended only for the purpose of providing the student with safe transportation to and from school. The student should be offered a seat close to the front of the bus (first 3 rows) so the driver may observe the student. This offer should be made while protecting the privacy of the student and the student/guardian may refuse this offer at any time. Student confidentiality must be maintained at all times. Be aware of and report any bullying of students related or unrelated to their medical condition. A copy of all health plans/medical alerts will also be kept in the front office and are made available to substitute/extra board bus drivers and aides. Substitute/extra board drivers will be required to go to the TOA office before beginning a shift to pick up/review the confidential or continuity folder containing Student Health Care Plans/Medical Alerts. 58

59 Drivers and/or bus aides should report any observed changes in a student s medical condition or behavior to their immediate TOA and the student s school nurse for investigation. The school nurse at each school will determine the necessity of training specific bus drivers and/or aides on the need for specific procedures on identified students including the administration of an EpiPen, application of VNS Magnet, and oral suctioning per CCSD Health Services Policies. The bus driver/aide must meet with the school nurse at the school of the identified student(s) once per month for verification of training. Bus drivers/aides may assist a student with self-administration of a medication/ procedure by assisting the student in locating the device/medication in a backpack/purse. All students who carry medications on their person in the bus must be deemed independent in the delivery of such medications. The school nurse will determine which students are independent in self-administration of medications following CCSD Health Services Policies. Bus drivers/aides may NOT administer a medication or perform a procedure unless they have been trained by the site school nurse for that student. In the event that a student goes into cardiac arrest or stops breathing, begin Cardio Pulmonary Resuscitation (CPR). If needed, verbal instructions can be provided by the 911 operator. Reference the student s care plan/medical alert for appropriate treatment during an emergency. Use universal precautions when warranted by wearing latex-free gloves. Drivers/aides should always enforce the no food/drink policy to avoid allergic reactions (both known and unknown) that may lead to anaphylactic shock. Exceptions to this policy may be required for students with certain medical conditions such as diabetes. In the event that a parent, guardian, student, or school personnel report that a student has a medical condition in which there is not a Health Care Plan/ Medical Alert notify your immediate TOA, TOM or site administrator. They will contact the Transportation Nurse for immediate investigation. Each year drivers and aides will complete the required Anaphylaxis Training. If at any time, the driver and/or aide request a refresher course, they should inform their immediate TOA or TOM. The Assistant or Manager will then work with the Support Staff Training Supervisor to coordinate the training. Drivers/aides should observe all students for possible life-threatening medical conditions. Some students may not be identified prior to their first episode. In the event of any life threatening incident, drivers/aides should contact dispatch to call 911. Employee Name: (print) Employee Signature: 59

60 Resources 60

61 Appendix A Sensitivity and Bullying A student with food allergies may become victim to bullying, intimidation, and harassment related to his/ her condition. Bullying, intimidation, and harassment diminish a student s ability to learn and a school s ability to educate. On July 1, 2011, the Nevada State Legislature passed Senate Bill 276 which defined bullying related terminology, declared a prohibition on bullying in public schools, the provision of training to school personnel and procedures for the reporting of incidents of bullying. Additionally, it required the principal of each public school to establish a school safety team, investigate reported bullying incidents and collaborate in the prevention of bullying. Procedures for reporting bullying incidents were also included. The statewide observance of the Week of Respect was determined to be the first week in October. The Nevada Revised Statutes define bullying (NRS ), cyber-bullying (NRS ), electronic communication (NRS ), harassment (NRS ), and intimidation (NRS ). State statutes continue to discuss the conditions of a safe and respectful learning environment, the conditions under which individual schools districts prescribe by regulation the components of a policy for all schools to provide a safe and respectful learning environment free of bullying, cyber-bullying, harassment, and intimidation. NRS discusses the establishment of a training program for district personnel; NRS and 1344 discuss the establishment and operation of a school safety team by the principal of each school. NRS outline legislative policy of prohibition of bullying with procedures for reporting of same. In response to the mandate of SB276, the Clark County School District Board of Trustees unanimously ratified the revision of CCSD Policy 5137: - Safe and Respectful Learning Environment: Bullying and Cyberbullying on 7/12/12. Policy 5137 includes definitions for bullying, cyberbullying, harassment, and intimidation. It outlines the requirements and methods for reporting bullying incidents, discusses the plan for appropriate professional development training of CCSD personnel. Each school s safety team, which is made up of administrators, teachers and parents, could be instrumental in the school s development of a policy to address bullying and food allergies. 1) Remind students and staff that bullying or teasing food-allergic students will not be tolerated and violators will be disciplined appropriately. 2) Offer professional development for faculty and staff regarding confidentiality to prevent open discussion about the health of specific students. 3) Discourage needless labeling of food-allergic students in front of others. A foodallergic student should not be referred to as the peanut kid, the bee kid or any other name related to the student s condition. 61

62 Appendix B Reading Food Labels In 2006, a new federal law, the Food Allergy Labeling Consumer Protection Act (FALCPA), took effect that requires manufacturers to clearly identify on the food label any ingredients that contain proteins from the eight major allergenic foods and food groups: milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat and soybeans. The label must clearly identify in plain English the source of any ingredient that is, or contains protein from, one of the eight foods or food groups. The law also requires that the label identify the type of tree nut (i.e. almonds, pecans, walnuts); the type of fish (i.e. bass, flounder, cod); and the type of crustacean shellfish (i.e. crab, lobster, shrimp). The law applies to all foods, both domestic and imported, except meat, poultry and egg products regulated by USDA s Food Safety and Inspection Service (FSIS), but FSIS is in the process of adopting the same standards through their rule making process. Food manufacturers are required to identify the presence of a major allergen on the label in one of three ways: 1. In the actual ingredient list 2. Immediately after or adjacent to the ingredient list, the word Contains followed by the name of the major allergen ( Contains milk ) 3. Via parenthetical statement after the scientific ingredient term ( albumin [egg]) A food product is subject to recall if it contains one of the eight major allergenic foods or food groups which is not properly declared on its label. Unfortunately, some products containing one or more of the top eight allergens may be sold with improper labels, whether or not they have been recalled. Additionally, FALCPA does not require special disclosure of the presence of allergens which are not one of the top eight allergens. For these reasons, it is important to carefully read every label and each of a food product s ingredients to ensure that it does not contain an allergen, prior to purchasing, ordering and serving foods. Common food allergens may be disclosed as an ingredient on a label using a less common name for the allergenic food or food group. For example, milk may be listed as whey, casein, or ghee; egg may be listed as albumin; and wheat may be listed as malt, bran, flour, spelt. You may contact The Food Allergy Research & Education (FARE) website for complete and current lists of all of the terms that may be used to reference top allergens. See Appendix F for more resources. Any domestic or imported packaged food regulated by the FDA is required to have a label that lists whether the product contains one of the top eight allergens. The top 8 allergens are milk, wheat, eggs, peanuts, tree nuts, fish, shellfish and soy. Fresh produce, fresh meat, certain highly refined oils, cosmetics, soaps and cleaning products do not require listing of potential food allergens on the labels. In addition, just because a food does not have a precautionary warning (may contain) does not mean the food is safe or that it has not been cross contaminated. Manufacturers are not required to include warnings about food allergens accidently introduced during manufacturing or packaging. Some manufacturers voluntarily provide advisory labeling. However, this is done in many different ways. (i.e., use of shared facilities or equipment or food may contain a specific allergen). A study by Hefle found that 7% of products with advisory labeling contained detectable peanut protein. (Hefle,SL et al., Journal of Allergy and Clinical Immunology) 62

63 Appendix C Constructive Classroom Rewards 63

64 Appendix C Constructive Classroom Rewards Reprinted with Permission from Healthy Schools Campaign and adapted from Center for Science in the Public Interest 64

65 Appendix C Constructive Classroom Rewards Reprinted with Permission from Healthy Schools Campaign and adapted from Center for Science in the Public Interest 65

66 Appendix D Emotional Wellness, Children with Potentially Life-Threatening Allergies Children can feel a range of emotions associated with their allergy: fear, sadness, anger, and loneliness. The two primary feelings are anxiety and depression. Several factors can influence the intensity of these emotions, among them the child s own temperament, his experience with allergic reactions, his age and the attitudes of his parents and teachers. Children who are naturally more timid may need additional assurance or coaching to ward off anxiety, while children who are not naturally apprehensive may need parents and teachers to instill a sense of caution. A child who has experienced a severe allergic reaction is more likely to be anxious about his allergy. Children look to the adults in their lives for cues on how to react to a situation. Confident and matterof-fact handling of the child s allergy tells him that he can accept his allergy and meet new situations with confidence and sensible caution. Age-appropriate safety education throughout the early years with an allowance of greater responsibility as the child matures will help to build confidence and a sense of control. Children don t want to be treated differently from classmates; they want to be part of the group and don t want their allergies highlighted. As a child matures, however, feelings of isolation or being different can develop into sadness and deepen into depression. If anxiety or depression affects schoolwork or relationships with friends or family members, parents/guardians may want to seek out professional assistance and support to help their child cope with these feelings. Parents/Guardians can also help by showing children, through books and music examples of food-allergic people who have not let food allergies hinder them from pursuing their goals. Another way to help children cope with everyday situations is through role-playing: parents and children can practice what to do and say when faced with challenging situations. If a child is invited to a party where food is a big part of the celebrations, parents/guardians can provide appealing and safe options so that the child doesn t feel left out, as well as provide or suggest food that all can eat. Encouraging children to develop friendships and to participate in activities that they enjoy helps them to define themselves and to mature. Allergies are a part of life that they cannot ignore, but they are just one part. Parents/Guardians and teachers should help children focus on what they can do, not what they can t, and to cheer them on as they follow their dreams. Support groups are available to help families and educators cope with the challenges of dealing with food allergies. Groups can be found by visiting The Food Allergy Research & Education (FARE) website. 66

67 67 Appendix E

68 68 Appendix F CONFIDENTIAL HS-65A 11/13

69 69 Appendix F CONFIDENTIAL HS-65C 11/13

70 70 Appendix F HS-58 7/13

71 71 Appendix F HS-96 11/12

72 72 Appendix F HS-96 Page 2