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Microsoft word - non-severe food allergy packet

NORTH ROYALTON CITY SCHOOLS
Request for Additional Information Concerning Food Allergy
The health care forms you submitted for:_________________________________ indicate thathe or she has a food allergy to:_______________________________.
If your child has a life-threatening food allergy requiring emergency medication (i.e.: EpiPen or
Benadryl), please forward the following items to the school:
 A current small picture of your child until we are able to photograph him or her. The picture will be placed on his or her Emergency Allergy Plan so that staff can recognize and identify yourchild.
 A signed Administration of Medication Request (attached) from both you and your child’s physician authorizing the school to administer medication in the event of an allergic reaction inschool.
 A signed Emergency Allergy Plan (attached) from both you and your child’s physician with instructions the school is to follow in the event of an allergic reaction in school.
 Two Epinephrine pens (EpiPen), if prescribed, or other medication such as Benadryl to be used if an allergic reaction occurs. The students are permitted to carry their own emergency medicationif authorized by the physician, parent/guardian, and the school. For those students who are notpermitted to carry the medication, it will be located in the clinic and readily available should theneed occur.
*Children who carry their own emergency medication MUST have the
appropriate documents on file in the school clinic.
If your child’s allergy is NOT life-threatening and does NOT require emergency medication, please
complete and return the Notification of Non-Emergent Food Allergy form (attached) with a
physician’s signature.

(A physician’s note declaring the medical/ dietary needs, food(s) to be
omitted, and food(s) to be used as substitutions will also be accepted). Please remember, food
services will NOT be notified until this information is received. Therefore, your child will not
receive any food substitutions should they attempt to purchase lunch until the District receives the
physician information.

Your prompt attention to this matter is greatly appreciated. If you should have any questions or wouldlike to meet to discuss your child’s allergy, please feel free to call me.
Michele L. Prezenkowski RN BSNDistrict Health Coordinator14709 Ridge RoadNorth Royalton, Ohio 44133440.582-9067 NORTH ROYALTON CITY SCHOOLS
Notification to School of Non-Emergent Food Allergy
Student’s Name:
Food Allergy/Intolerance to:
Food(s) to be Omitted
Possible Reactions Student May Experience
Foods to be used as substitutions
In the event of an exposure and reaction, please do the following:
1.
2.
3.

* Please remember, food services will NOT be notified until this form is received with a
physician’s signature or a physician’s note stating the medical/dietary need, the foods to be
omitted, and the foods to be used as substitutions is provided. Therefore, your child will
NOT receive any food substitutions, should they attempt to purchase lunch, until the
District receives a physician’s notification.

I GIVE PERMISSION FOR SCHOOL PERSONNEL TO FOLLOW THIS PLAN, ADMINISTER MEDICATION (IF
ANY) AND CARE FOR MY CHILD AND CONTACT MY PHYSICIAN IF NECESSARY.

I ASSUME FULL
RESPONSIBILITY
PROVIDING
PRESCRIBED
MEDICATION
DELIVERY/MONITORING DEVICES. I APPROVE THIS ALLERGY PLAN FOR MY CHILD. I ALSO CONSENT
TO THE RELEASE OF THE INFORMATION CONTAINED IN THIS PLAN TO ALL STAFF MEMBERS AND
OTHER ADULTS WHO HAVE CUSTODIAL CARE OF MY CHILD AND WHO MAY NEED TO KNOW THIS
INFORMATION TO MAINTAIN MY CHILD’S HEALTH AND SAFETY.

THE NON-EMERGENT FOOD ALLERGY PLAN HAS BEEN FORWARDED TO THE FOLLOWINGINDIVIDUALS/DEPTS.
NORTH ROYALTON CITY SCHOOLS
Food Safety Guidelines
North Royalton City Schools takes its commitment to provide a safe learning environment for allindividuals seriously. In recent years, the increased number of students with life-threateningfood allergies is more evident in our buildings. Most common life-threatening allergens include:peanuts, tree nuts, eggs and milk/milk products. Although it may seem simple, there is no wayto ensure a building is “allergen-safe”, especially with the vast variety of allergies. A school-wide ban of an allergen may not render the environment absolutely safe because there is nomethod for ensuring that the allergen does not inadvertently come into the school.
Therefore, we are taking proactive steps to help reduce a possible allergen exposure for thechildren.
One important step includes the annual training of all staff about food allergies including the most common food allergens, signs and symptoms of a reaction, and emergencymedication administration. Also, we have eliminated the sharing of all home-baked goods withother students at the ECC & Elementary Buildings.
classroom party snacks) must be selected from an approved list that is free of the four mostcommon food allergies (milk, egg, peanut, tree nut). The list is available on our web site or inyour child’s building packet. Also, an Emergency Allergy Plan will be initiated for each childwho has a life-threatening food allergy upon receipt of a physician’s note documenting theallergy and the severity. The Emergency Allergy Plan will include a step-by-step guide for thatchild in case of an allergic reaction.
An initial meeting may be requested of the parents so that the school staff is better informed of the allergy.
Finally, if determined necessary, designated locations within the lunch area will be reserved for those students with severe food allergies.
Children without allergies can also sit in these “zones”, provided their food does not contain theallergen. Those tables will be cleaned by adult staff with the appropriate supplies.
To ensure the safety of the child, the program will require participation by all. Each individualhas his or her own responsibilities: FAMILY’S RESPONSIBILITY:
 Notify the school of the child’s allergies and provide a physician’s note documenting the allergy, the food(s) to omit, and the food(s) to substitute regardless of the severity:
For children with NON life-threatening allergies that do NOT require emergency
medication (EpiPen or Benadryl), please complete and return the ‘Notification of
Non-Emergent Food Allergy’ form NSG-200G with a physician’s signature.
*Please note that food services will NOT be notified until your physician has
completed this form or sends in other medical documentation. Therefore,
your child will NOT receive any food substitutions should they attempt to
purchase lunch until the District receives the appropriate medical
documentation.

For children with life-threatening allergies, please provide the following
documentation: Emergency Allergy Plan (NSG-200F) & the Administration of Medication Request
Form (NSG-300A)
Parents are encouraged to pack their child’s lunch until this information is madeavailable to the school.
 Provide properly labeled medications and replace them after use or expiration.
 Provide current emergency contact information in case of an incident.
 Contact the school’s Cafeteria Manager via phone on those days that the child will be  High School Cafeteria 2: Mary Ellen Feigi (440) 582-7801 x 3627 Middle School Cafeteria: Beth Schneider  Early Childhood Center: Donna DeStefanis (440) 582-9039 x 3085 REMINDER: The parents of those children who have a life-threatening allergy which may
cause an anaphylactic reaction who choose to purchase lunch on any given day MUST
contact the kitchen the day they wish to purchase lunch. The manager will review that
day’s menu. If the parent does not call the kitchen on the day that the lunch is purchased,
the cafeteria manager will (to the best of her ability) only allow the student to purchase
lunch items which do not contain the allergen.

 Consider providing a medical alert bracelet for your child.
 Request a meeting with the school team to develop a plan that accommodates the child’s  Communicate with the teacher often regarding upcoming parties and treats and participate in party planning and field trips.
 Educate the child in the self-management of their food allergy including: Strategies for avoiding exposure to unsafe foods.
Signs and symptoms of allergic reactions.
How and when to tell an adult they may be having an allergy-related problem.
How to read food labels (age appropriate).
Discourage the consumption of vending and snack cart products.
SCHOOL’S RESPONSIBILITY:
 Be knowledgeable about and follow applicable federal laws that apply.
 Review the health records submitted by parents and physicians.
 Identify a core team of staff to work with the parents and the student to establish the  Educate all staff annually regarding food allergies including recognition of signs/symptoms of a reaction, how to react in an emergency situations, medicationadministration, and the further prevention of a reaction.
 Ensure that medications are current and appropriately stored according to district policy in a central location for easy access.
 Designate several school personnel who are properly trained to administer the emergency medication in the absence of the healthcare professional.
 Collaborate with District Transportation to assure the safety of the student on the bus.
 Collaborate with Food Services regarding the identity of the student and the allergen.
 Provide substitute/alternate food choices, if needed, for the child.
 Discuss field trips with the family to decide appropriate strategies for the trip.
 Review policies annually and more frequently as needed.
STUDENT’S RESPONSIBILITY:
 Learn to recognize symptoms of an allergic reaction.
 Comprehend that food should not be shared or traded with others.
 Understand that he or she should not eat anything with unknown ingredients or ingredients known to contain an allergen.
 Be proactive in the care and management of their food allergies and reactions based on  Notify an adult immediately if they eat something they believe may contain the food to which they are allergic or if displaying signs/symptoms of a food reaction.
 Carry the emergency medication (if applicable) at all times.
North Royalton City Schools are committed to providing a safe learning environment for allstudents. In continuing to provide a safe environment for our students with life-threatening andnon life-threatening food allergies, we are asking all parents for cooperation and assistance in ourplan. If you should have any questions, please feel free to call our Food Service Director, SueJordan, at (440) 582-9041 or our District Health Coordinator, at (440) 582-9067.

Source: http://www.northroyaltonsd.org/public/files/non_severe_food_allergy.pdf?PHPSESSID=95694ac64984ccb5ec1252e26db4c1ef

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