Report of Epinephrine Administration
The revised Regulations Governing the Administration of Prescription Medications in Public and Private Schools (105 CMR 210.000) require schools to submit a written report to the Department of Public Health each time epinephrine is administered to a student or staff, on a form obtained from the Department. The reports are reviewed as part of a continuous quality improvement program for the School Health Unit.
Online Epinephrine Administration Reporting Process
Please review instructions below before submitting online report as once you submit your report it cannot be re-opened or edited.
This epinephrine administration reporting form must be completed in one session. If you close the form before clicking the "Submit" button, everything you have entered will be lost.
Please have all of the necessary information regarding the epinephrine administration available to complete the online form before you begin data entry.
This form must be completed online. No paper printouts or electronic computer files will be accepted.
Reporting Form Navigation Instructions
Use the Tab key to move to the next question (or just click on the response to the next question). Hitting the "Enter" key is the same as clicking the "Submit" button, so do not hit Enter after completing each question or it will take longer to complete the form.
To Print a Copy of the Form
For a hard copy, print the form BEFORE clicking "Submit." After you submit the report, you will not be able to view or print it.
Link to Online Epinephrine Report: http://webapps.ehs.state.ma.us/ReviewSurvey/ReviewSurvey.aspx?id=297
Please try to enter data as accurately and as completely as possible so that it will not need to be corrected later. If it is necessary to make corrections to the form after you submit it, please e-mail corrections to DPH ESHS_data@dph.state.ma.us. Please do not submit more than 1 report for the same administration or it will be counted as two separate administrations.
If You Have Questions
For clinical technical assistance regarding the administration of epinephrine, please contact your MDPH School Health Advisor.
For technical assistance regarding submission of this form, please e-mail email@example.com.
Report of Drug Incident
The Massachusetts Department of Public Health Drug Control Program requires school districts to report drug incidents and/or diversions.The goal of the Drug Diversion Control Unit is to reduce the opportunities for theft, tampering, misuse and abuse of pharmaceuticals. The unit establishes standards for effective security and accountability of drugs; ensures compliance by health care facilities, manufacturers/distributors and community-based programs; and provides education to health care providers and the general public. In the event of a drug incident and/or diversion, school district personnel (preferably a school physician, school nurse leader or school nurse), should complete and return the Drug Incident Report Form. Please send the completed form directly to the Drug Control Program at the address listed below.
For additional information please contact the Drug Control Program directly at the following address or visit their website:
Drug Control Program
99 Chauncy Street
Boston, MA 02111
This information is provided by the School Health Services within the Department of Public Health.