ࡱ> >A= 1bjbjWW >55,(((8`|(6kkk46666666666666$8E;Z6kkkkkZ6o6kL46k46147uR3* 660637< 7<T47<4lkkkkkkkZ6Z6kkk6kkkk7<kkkkkkkkk : Employee Administration of Epinephrine by Autoinjector Opt Out Form* I, _____________________________, an employee of _______________School District, hereby exercise my right to refuse to administer epinephrine by autoinjector to any student under any circumstances pursuant to Chapter 28A.210, RCW. I affirm that I have not agreed in writing to the use of epinephrine autoinjectors as a specific part of my job description. I agree that my refusal does not absolve me from attending any staff trainings regarding anaphylaxis prevention and/or response as required by my supervisor or job description. I understand that this specific refusal will not serve as grounds for my discharge, contract nonrenewal or any other adverse action affecting my contract status. I further understand that this refusal will remain in effect until the next annual training prior to the start of school, or until I withdraw it in writing, whichever occurs first. I also understand that to continue my refusal, I must sign a new opt-out form each year during annual training prior to the start of school. ________________________________ Employee Signature and Date ________________________________ Superintendent/Principal or Designee Signature and Date ________________________________ School Nurse Signature and Date cc: Employee file *It is recommended that the district make this form available to staff each year during annual training prior to the start of school. Adoption Date: School District Name: Revised:     Form-1, Policy 3420 Students 8DEFG , ? M ` w 8 ? {  $ E Ǽxj\Nj\jNjh /B*aJmH phsH hSB*aJmH phsH h~B*aJmH phsH !h{Qh{QB*aJmH phsH !heh{QB*aJmH phsH !hehYB*aJmH phsH !hehdB*aJmH phsH h@Q>*aJmH sH h /hs$56mHnHsH h /5mHnHsH h /mHnHsH hYmHnHsH h'3mHnHsH 8FG` F G h ! 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