Annual Risk Management Checklist School Name: Date of Review: Who completed this checklist? Name: Position: Review to: Name Position Comments: General Information How many current students have been diagnosed as being at risk of anaphylaxis, and have been prescribed an Adrenaline Autoinjector? How many of these students carry their Adrenaline Autoinjector on their person? Have any students ever had an allergic reaction requiring medical intervention at school? Yes No If Yes, how many times? Have any students ever had an Anaphylactic Reaction at school? Yes No If Yes, how many students? If Yes, how many times Has a staff member been required to administer an Adrenaline Autoinjector to a student? Yes No If Yes, how many times? Was every incident in which a student suffered an anaphylactic reaction reported via the Incident Reporting and Information System (IRIS)? Yes No SECTION 1: Individual Anaphylaxis Management Plans Does every student who has been diagnosed as being at risk of anaphylaxis and prescribed an Adrenaline Autoinjector have an Individual Anaphylaxis Management Plan and ASCIA Action Plan completed and signed by a prescribed Medical Practitioner? Yes No Are all Individual Anaphylaxis Management Plans reviewed regularly with Parents (at least annually)? Yes No
Has someone been designated to check the Adrenaline Autoinjector expiry dates on a regular basis? Who? …………………………………………………………………………………………… Yes No Are Adrenaline Autoinjectors which are currently in the possession of the School and which have expired? Yes No Has the School signed up to EpiClub or (optional free reminder services)? Yes No Do all School Staff know where the Adrenaline Autoinjectors and the Individual Anaphylaxis Management Plans are stored? Yes No Has the School purchased Adrenaline Autoinjector(s) for General Use, and have they been placed in the School’s first aid kit(s)? Yes No are these first aid kits located? Is the Adrenaline Autoinjector for General Use clearly labelled as the ‘General Use’ Adrenaline Autoinjector? Yes No Is there a register for signing Adrenaline Autoinjectors in and out when taken for excursions, camps etc? Yes No SECTION 3: Prevention Strategies Have you done a risk assessment to identify potential accidental exposure to allergens for all students who have been diagnosed as being at risk of anaphylaxis? Yes No Have you implemented any of the prevention strategies in the Anaphylaxis Guidelines? If not record why? Yes No Have all School Staff who conduct classes with students with a medical condition that relates to allergy and the potential for anaphylactic reaction successfully completed an Anaphylaxis Management Training Course in the three years prior and participated in a twice yearly briefing? Yes No Are there always sufficient School Staff members on yard duty who have successfully completed an Anaphylaxis Management Training Course in the three years prior? Yes No SECTION 4: School Management and Emergency Response Does the School have procedures for emergency responses to anaphylactic reactions? Are they clearly documented and communicated to all staff? Yes No Do School Staff know when their training needs to be renewed? Yes No Have you developed Emergency Response Procedures for when an allergic reaction occurs? Yes No In the class room? Yes No In the school yard? Yes No