Emergency Information Forms 
for Special Needs Children 

The American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) have worked for over two years to develop an Emergency Information Form that standardizes information that would be helpful to emergency medical personnel. Both groups have also developed formal policy statements regarding the use of this form. MedicAlert® will store the information in its 24-hour Emergency Response Center if the child participates in the MedicAlert® program.

The Emergency Information Form is completed by the child's primary care physician and can then be given to the parent, childcare provider, and/or school nurse. The suggested form entitled "Emergency Information Form for Children With Special Health Care Needs" includes essential data elements such as the patient's name, birth date, date of last summary update, weight, guardian's name, emergency contacts, pediatricians and other health care professionals, primary emergency department, major chronic illnesses and disabilities, baseline physical and mental status, baseline vital signs and laboratory studies, immunization history, medications, medication allergies, food allergies, and a advanced directives.* It can also be kept on file at the EMS service, EMS dispatch center, or Emergency Department. The biggest challenge is keeping the information on the form up to date. Pediatric specialists and subspecialists are being encouraged to keep the child's primary care physician updated so that he or she can update the Emergency Information Form.

To encourage the dissemination of this form, many states are distributing it to EMS providers, school nurses, childcare providers, hospitals, and discharge planners. Other targeted groups include pediatricians and community organizations such as local interagency coordinating councils, local mental health/mental retardation agencies, intermediate units, and any other organizations that deal with specific chronic diseases (e.g., epilepsy, cerebral palsy, spina bifida, diabetes, etc.). 

Feel free to download the form and begin using it in your area. If you would like additional information or have specific questions, please contact the EMSC National Resource Center at (800) 360-9296 or MedicAlert® at (800) 432-5378. 

More information about the form is available at 
http://www.pediatrics.org/cgi/content/full/104/4/e53 

Click on the images below to access a printable copy. Each image is approximately 270K.

First (or 2) pages