Epinephrine Autoinjector

Reporting of Epinephrine Autoinjector Use

Ohio Revised Code Chapter 3728 allows a Qualified Entity to maintain and administer epinephrine to an individual experiencing anaphylaxis (a life-threatening allergic reaction).

Who is a Qualified Entity?

"Qualified entity" means any public or private entity that is associated with a location where allergens capable of causing anaphylaxis may be present, including: Child day-care centers, Colleges and universities, Places of employment, Restaurants, Amusement parks, Recreation camps, Sports playing fields and arenas, and Other similar locations.

NOTE: “Qualified Entity” does not mean: Chartered or nonchartered nonpublic school, Community school, Science, technology, engineering, and mathematics (STEM) school, School operated by the board of education of a city, local, exempted village, or joint vocational school district, or a residential camp or day camp.

These entities are authorized under other law to procure, maintain and administer epinephrine autoinjectors and must report to the Ohio Department of Education at http://education.ohio.gov/Topics/Other-Resources/Epinephrine-Procurement.

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* 1. "Did the incident occur at either of the following?
(1) A chartered or nonchartered nonpublic school; community school; science, technology, engineering, and mathematics school; or a school operated by the board of education of a city, local, exempted village, or joint vocational school district;
(2) A camp described in section 5101.76 of the Revised Code."

Yes

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* 2. Qualified Entity Name

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* 3. Qualified Entity Address 1

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* 4. Qualified Entity Address 2

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. County

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* 9. Contact Name

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* 10. Contact Phone

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* 11. Contact Email

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* 12. Check here if location of Epinephrine Autoinjector administered same as Qualified Entity Location?

Yes

Note: Questions 15-21 are asking about the location where the epinephrine was used.

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* 13. Location Name Epinephrine Autoinjector Administered

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* 14. Location Name Epinephrine Autoinjector Administered Address 1

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* 15. Location Name Epinephrine Autoinjector Administered Address 2

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* 16. City

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* 17. State

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* 18. Zip Code

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* 19. County

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* 20. Contact Name

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* 21. Contact Phone

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* 22. Contact Email

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* 23. Number of Epinephrine Autoinjector administered

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* 24. Lot Number - 1

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* 25. Expiration Date - 1

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* 26. Lot Number - 2

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* 27. Expiration Date - 2

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* 28. Known Allergen?

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* 29. Member of the Public or Employee?

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* 30. Was the victim an Adult or Child?