Anaphylaxis Emergency Record

About the Anaphylaxis Emergency Record

A digital anaphylaxis emergency record designed to comply with Regulations 90 and 94 of the Education and Care Services National Regulations. This form captures the child's symptoms, suspected allergen, whether the action plan was followed, EpiPen administration details including dose, time, and injection site, ambulance and hospital details, witness information, and parent notification. The multi-step signing workflow ensures responsible person review and parent acknowledgement.

Also called

  • Anaphylaxis record
  • Allergic reaction record
  • Adrenaline autoinjector administration record

What's on this form

Every question included in the anaphylaxis emergency record. Add, remove or reword any of them in the form builder.

Step 1 — Completed first

Filled in by the educator or responsible person

  • Child Details

    Child details

  • Incident Details

  • Date of Incident

    Date

  • Time Symptoms Observed

    Time

  • Session

    • Before School Care
    • After School Care
    • Vacation Care
    • Long Day Care

    Choose one

  • Signs and Symptoms Observed

    Long answer

  • Suspected Allergen or Trigger

    Long answer

  • Treatment

  • Was the child's Anaphylaxis Action Plan followed?

    Yes / No

  • Describe actions taken

    Long answer

  • Was an adrenaline autoinjector (EpiPen) administered?

    Yes / No

  • Medication Name and Dose

    Short answer

  • Time Administered

    Time

  • Injection Site

    • Left outer mid-thigh
    • Right outer mid-thigh

    Choose one

  • Autoinjector Expiry Date

    Short answer

  • Was a second dose administered?

    Yes / No

  • Emergency Services

  • Was an ambulance called?

    Yes / No

  • Time Ambulance Called

    Time

  • Time Ambulance Arrived

    Time

  • Was the child transported to hospital?

    Yes / No

  • Hospital Name

    Short answer

  • Witness Details

  • Witness Nameoptional

    Short answer

  • Witness Accountoptional

    Long answer

  • Parent Notification

  • Time Parent/Guardian Notified

    Time

  • Person Notified

    Short answer

  • Contact Number Used

    Mobile

  • Administered By

    Educator signature

Step 2 — Responsible Person

Completed by a staff member at the service

  • Responsible Person Details

    Educator signature

  • Parent / Guardian Signature

    Signature

How this form gets signed

This template runs as a multi-step signing workflow. Each person is notified in turn, and every signature is timestamped and stored against the record.

  1. 1

    Responsible Person

    Signs inside the service, using a staff PIN

  2. 2

    Parent/Guardian

    Signs externally — receives a secure link by email, no account needed

Australian regulations this form supports

The anaphylaxis emergency record is built around the Education and Care Services National Regulations. These are the regulations it helps you meet.

Reg 90

Medical conditions policy

Services must have a medical conditions policy covering anaphylaxis management. The child's medical management plan must be followed during incidents.

Read the full text of Reg 90

(1) The medical conditions policy of the education and care service must set out practices in relation to the following— (a) the management of medical conditions, including asthma, diabetes or a diagnosis that a child is at risk of anaphylaxis; (b) informing nominated supervisors and staff members of, and volunteers at, the service of practices in relation to managing those medical conditions; (c) the requirements arising if a child enrolled at the education and care service has a specific health care need, allergy or relevant medical condition, including— (i) requiring a parent of the child to provide a medical management plan for the child; and (ii) requiring the medical management plan to be followed in the event of an incident relating to the child's specific health care need, allergy or relevant medical condition; and (iii) requiring the development of a risk-minimisation plan in consultation with the parents of a child— (A) to ensure that the risks relating to the child's specific health care need, allergy or relevant medical condition are assessed and minimised; and (B) if relevant, to ensure that practices and procedures in relation to the safe handling, preparation, consumption and service of food are developed and implemented; and (C) if relevant, to ensure that practices and procedures to ensure that the parents are notified of any known allergens that pose a risk to a child and strategies for minimising the risk are developed and implemented; and (D) to ensure that practices and procedures ensuring that all staff members and volunteers can identify the child, the child's medical management plan and the location of the child's medication are developed and implemented; and (E) if relevant, to ensure that practices and procedures ensuring that the child does not attend the service without medication prescribed by the child's medical practitioner in relation to the child's specific health care need, allergy or relevant medical condition are developed and implemented; and (iv) requiring the development of a communications plan to ensure that— (A) relevant staff members and volunteers are informed about the medical conditions policy and the medical management plan and risk minimisation plan for the child; and (B) a child's parent can communicate any changes to the medical management plan and risk minimisation plan for the child, setting out how that communication can occur. (2) The medical conditions policy of the education and care service must set out practices in relation to self-administration of medication by children over preschool age if the service permits that self-administration. (3) In subregulation (2), the practices must include any practices relating to recording in the medication record for a child of notifications from the child that medication has been self-administered.

Reg 94

Exception to authorisation requirement — anaphylaxis or asthma emergency

In a medical emergency including anaphylaxis, medication may be administered without prior written authorisation if the child's parent cannot be contacted and a medical practitioner or emergency service advises administration.

Read the full text of Reg 94

(1) Despite regulation 93, medication may be administered to a child without an authorisation in case of an anaphylaxis or asthma emergency. (2) If medication is administered under this regulation, the approved provider or a nominated supervisor of the education and care service or family day care educator must ensure that the following are notified as soon as practicable— (a) a parent of the child; (b) emergency services.

Reg 92

Medication record

A medication record must include the child's name, medication name, dosage, time administered, and signature of the person who administered it.

Read the full text of Reg 92

(1) The approved provider of an education and care service must ensure that a medication record is kept that includes the details set out in subregulation (3) for each child to whom medication is or is to be administered by the service. (2) A family day care educator must keep a medication record that includes the details set out in subregulation (3) for each child being educated and cared for by the educator as part of a family day care service to whom medication is or is to be administered. (3) The details to be recorded are— (a) the name of the child; (b) the authorisation to administer medication (including, if applicable, self-administration), signed by a parent or a person named in the child's enrolment record as authorised to consent to administration of medication; (c) the name of the medication to be administered; (d) the time and date the medication was last administered; (e) the time and date, or the circumstances under which, the medication should be next administered; (f) the dosage of the medication to be administered; (g) the manner in which the medication is to be administered; (h) if the medication is administered to the child— (i) the dosage that was administered; and (ii) the manner in which the medication was administered; and (iii) the time and date the medication was administered; and (iv) the name and signature of the person who administered the medication; and (v) if another person is required under regulation 95 to check the dosage and administration, the name and signature of that person.

Provided for information only and may not reflect the latest amendments. Refer to the Education and Care Services National Regulations (NSW) for the official legal text.

Where this form fits

The anaphylaxis emergency record is part of these jobs — each guide walks through the whole sequence and the other forms that go with it.

Questions about the anaphylaxis emergency record

What is the anaphylaxis emergency record used for?

A digital anaphylaxis emergency record designed to comply with Regulations 90 and 94 of the Education and Care Services National Regulations. This form captures the child's symptoms, suspected allergen, whether the action plan was followed, EpiPen administration details including dose, time, and injection site, ambulance and hospital details, witness information, and parent notification. The multi-step signing workflow ensures responsible person review and parent acknowledgement.

Who fills in the anaphylaxis emergency record?

The anaphylaxis emergency record is completed by educators or the responsible person at the service. Staff open it on any device and sign with a service PIN, so there's no separate login to manage. It then moves through 2 signing steps — Responsible Person and Parent/Guardian — with each signature timestamped against the record.

Which Australian regulations does the anaphylaxis emergency record meet?

It is built around Reg 90, Reg 94 and Reg 92 of the Education and Care Services National Regulations. Reg 90 covers medical conditions policy. Reg 94 covers exception to authorisation requirement — loss of consciousness or anaphylaxis. Reg 92 covers medication record. Every question the regulations require is already on the form.

Is the anaphylaxis emergency record the same as an anaphylaxis record?

Yes. Different services use different names for this form — it is also called anaphylaxis record, allergic reaction record and adrenaline autoinjector administration record. They all describe the same record, and this template covers it. You can rename it to whatever your service already calls it.

Can I change the questions on the anaphylaxis emergency record?

Yes. The template comes with 32 fields ready to go, but you can add, remove, reword or reorder anything in the drag-and-drop form builder, and add your own conditional logic and signing steps. Your changes only affect your service's copy.

Is the anaphylaxis emergency record free?

Yes — the anaphylaxis emergency record is free to use on the Childcare Forms free plan. No credit card is required to create an account and start sending it.

Ready to use it?

Create a free account, change anything you want, and send it to your first family. No credit card needed.