North Smithfield School Department PO Box 72 • 83 Green Street • Slatersville, RI 02876-0072 Telephone: (401)769-5492 Fax: (401)769-5493 R.I. Relay: (800)745-5555 Michael C. St. Jean, Superintendent of Schools September 2016 Anaphylaxis - Use of Bus Epinephrine Parent Notification Dear Parent/Guardian: To insure the health and safety of your child on the bus, the North Smithfield School Department and DATTCO School Bus Transportation Company provides the following information to fulfill the procedures specified in Section 16-21-22 of the Rhode Island General Laws in Chapter 16-21 entitled “Health and Safety of Pupils.”  Parents/Guardians who want auto-injectable epinephrine available on the bus to and from school as an emergency supportive intervention must authorize your child to self-carry his/her auto-injectable epinephrine [exception is Preschool through Grade 1.] Please see “PERMISSION FORM/CHECKLIST Preschool through Grade 1.” Therefore, if you opt for this, please: 1. Provide DATTCO School Bus Transportation Company with the following written information: a. Your child is “medically identified as being prone to anaphylaxis” and, b. You must provide a copy of a Licensed Health Care Provider’s current prescription order, and, c. You must provide written authorization from the Licensed Health Care Provider stating the child/student “is authorized to self-carry his/her auto-injectable epinephrine.” You may mail or drop off the written documentation at the DATTCO terminal located at: • Physical/Mailing Address: 706 St. Paul Street, North Smithfield, RI 02896 o Drop off must occur between the hours of 8:00 am and 3:00 pm.

School bus drivers are not allowed to accept the required information, etc., from parents.

Should you have any questions, please contact your child’s school nurse. cc:

School Nurses Ms. Pepler, DATTCO Mrs. Forget, DATTCO Mr. Meo, Transportation Director *SEE PERMISSION FORM/CHECKLISTS ATTACHED* Our mission is to prepare each student to be a successful and responsible member of society.

The North Smithfield School Department does not discriminate on the basis of age, race, religion, national origin, color or handicap in accordance with applicable laws and regulations.

ANAPHYLAXIS - USE OF BUS EPINEPHRINE

PERMISSION FORM/CHECKLIST Grade 2 through 12 All information must be provided simultaneously – partial submission is not accepted and cannot be tracked.

This form will be accepted by DATTCO only when accompanied by the following items: ____ Copy of a Licensed Health Care Provider’s current prescription order ____ Written authorization from the Licensed Health Care Provider stating the child is allowed to self-carry their auto-injectable epinephrine.

 My child, ______________________________________________, has been medically identified as being prone to anaphylaxis. I authorize my child to self-carry their auto-injectable epinephrine on the bus in case of an emergency. My child attends [school] Rides Bus #____ in the a.m.

[grade] and Bus# ____ in the p.m.

My child: ____will be self-carrying his/ her auto-injectable epinephrine (self-carry authorization required.)

Parent/ Guardian Signature

Date

ANAPHYLAXIS - USE OF BUS EPINEPHRINE PERMISSION FORM/CHECKLIST Preschool through Grade 1

All information must be provided simultaneously – Partial submission is not accepted and cannot be tracked.

This form will be accepted by DATTCO only when accompanied by the following items: ____ Copy of a Licensed Health Care Provider’s current prescription order  My child, ______________________________________________, has been medically identified as being prone to anaphylaxis.

My child attends North Smithfield Elementary School Rides Bus #____ in the a.m.

Grade

and Bus# ____ in the p.m.

_____ My child is in Kindergarten or First Grade; therefore, I will provide the bus driver with the EpiPen in a container clearly marked with my child’s name and maintain the EpiPen usability. The EpiPen container will be given to a teacher on duty in the morning; be provided to the driver in the afternoon; and, be given to the parent upon the child’s departure from the bus. This form will be accepted by DATTCO only when accompanied by the following items:  My child, ______________________________________________, has been medically identified as being prone to anaphylaxis. . ____ Copy of a Licensed Health Care Provider’s current prescription order My child attends North Smithfield Elementary School Rides Bus #____ in the a.m.

Parent/ Guardian Signature

Grade

and Bus# ____ in the p.m.

Date