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DOH-61e (2/03) NEW YORK STATE DEPARMTENT OF HEALTH Bureau of Community Environmental Health and Food Protection Children’s Camp Program Epinephrine Administration Instructions: See Instructions on back of form prior to completing eHIPS Incident Number: FACILITY INFORMATION Camp Facility Camp Type: R Day R Overnight Camp for developmentally disabled? R Yes R No Date to Local Health Department Incident Date: Incident Time: (Military time) Location of Incident: R In Camp R Out-of-Camp Does the camp participate in the Epinephrine administration program? R Yes R No Was the camp emergency care provider notified of the incident? R Yes R No VICTIM INFORMATION eHIPS Victim ID: Name of Patient: Home Address Street Town, Village or City Name of Parent or Guardian Home Phone Number ( ) Material in shaded area is confidential Age: Weight:______ Sex: R Female R Male Status: R Camper R Developmentally Disabled Camper R CIT/Jr. Counselor R Counselor R Other Staff* R Other* Specify for EVENT INFORMATION Type of Incident Resulting in Need to Administer Epinephrine: R Bee Sting R Other Insect Bite * R Asthma Attack R Food Allergy* R Other* * Time Epinephrine administered: (Military time) Number of auto-injector Type of Epinephrine Injector: R Epi-pen® R Epi-pen Jr.® R Other Where on body was epinephrine Indicate source of Epinephrine: R Camp supply R Patient prescription R Other Epinephrine Administered by: Indicate applicable certification(s) below R Doctor R Nurse Practitioner R Physician’s Assistant R RN R LPN R EMT R First Aid Certified Staff R Self-Administered R Other Epinephrine training course: R NYS EMS R Red Cross R None R Other Name of EMS agency providing Name and location of health care facility patient was transported Was patient admitted? R Yes R No Narrative: Provide a written description of the event on back of form. ---PAGE BREAK--- DOH-61e (2/03) Instructions for completing the Children’s Camp Epinephrine Administration Report Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure. Children’s camps must report epinephrine administration to the local health department whether or not they are participating in the auto injector program and regardless if medication was from the camp’s stocked supply or brought to camp by a camper or staff. Description of Incident: Describe and circumstances surrounding the administration of the Epinephrine including the cause of anaphylaxis, signs and displayed by the patient prior to administration and the patient’s response to the administered drug. Enter the events in the chronological order of their occurrence. Include available information about the event’s outcome such as whether the patient was discharged from the hospital, returned to camp or went home. Use additional sheets if needed. When entering the narrative into eHIPS do not enter confidential information. Use the victims initials or similar code. Report completed Date: Local Health Phone: