Epinephrine Standing Orders

Point of Contact Information

First Name

Last Name

Position / Title

Public Phone Number

Work Email Address

Work Email Address Confirmation

School / Education Organization

Organization Name

Organization Type

If selecting "Other Educational Organization", please specify:

Address Line 1

Address Line 2

City

County

Zip Code

Number of schools on behalf of which you are applying:

Please provide your County-District-School (CDS) code:

Look up your CDS code here.

Please list the official name of every school for which you are applying. If applying for more than one school, please list each school by name and list one school per line, pressing enter after each school to add a line break. *
Example:
ABC Elementary
ABC Middle
ABC High

Please select the options below for the school(s) on behalf of which you are applying:

Epinephrine Administration

How many and which type of epinephrine delivery devices are you applying for?
The maximum quantity of epinephrine auto-injectors allowed by this standing order, either regular or junior, is four per school, per calendar year.
The maximum quantity of epinephrine nasal spray devices allowed by this standing order, either 2mg or 1mg, is four per school, per calendar year.
Schools may request either or both types of epinephrine delivery devices up to the maximum number for each type.

Regular auto-injectors:

Must apply in multiples of two (2). Please enter zero (0) if no regular auto-injectors are needed.

Junior auto-injectors:

Must apply in multiples of two (2). Please enter zero (0) if no junior auto-injectors are needed.

2mg nasal spray devices:

Must apply in multiples of two (2). Please enter zero (0) if no 2mg nasal spray devices are needed.

1mg nasal spray devices:

Must apply in multiples of two (2). Please enter zero (0) if no 1mg nasal spray devices are needed.

To the best of your knowledge, in the past 12 months, has epinephrine been administered on a school site to person(s) believed to be in need of emergency medical aid?

Attestation

By submitting the online application form, the entity:

Certifies that the contact and location information provided is correct.
Will ensure that any of its affiliates or subcontractors apply for their own standing order.
Agrees the authority granted is conditioned on the completion of the CDPH Epinephrine Standing Order online application.
Agrees to allow the California Department of Public Health to contact the entity using the information provided on the application form.
Agrees to allow the California Department of Public Health to use the information provided on the application form to track the use of the standing order and conduct other public health and epidemiological surveillance activities.
Acknowledges that the standing order cannot be used to sell epinephrine delivery systems.
Agrees to ensure that entities and individuals receiving and administering epinephrine receive initial and annual refresher training, based on the standards developed inEducation Code 49414.
Agrees to maintain and report, at the time of renewal, information regarding the number of doses of epinephrine administered and cases of suspected anaphylaxis treated using epinephrine delivery systems distributed under this standing order.
Agrees to re-register for the standing order if there is a change in the information required on this form.
Agrees to maintain a copy of the standing order, which will include these terms and conditions.

CDPH Standing Orders

Epinephrine Standing Orders

Point of Contact Information

School / Education Organization

Please select the options below for the school(s) on behalf of which you are applying:

School Category

School Type

Attestation

Epinephrine Standing Orders

Point of Contact Information

School / Education Organization

​​Please select the options below for the school(s) on behalf of which you are applying:

School Category

School Type

Attestation

Please select the options below for the school(s) on behalf of which you are applying: