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EPI-2016-0317 CERTIFICATION FORM: Free ... - RxAssist

EPI-2016-0317 CERTIFICATION FORM: Free ... - RxAssist-2026

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The document is a certification form for the EpiPen4Schools Program, which allows schools to receive free EpiPen Auto-Injectors for emergency treatment of anaphylaxis. It outlines the responsibilities and conditions that schools must agree to in order to participate, including providing accurate information, ensuring proper training for staff, and prohibiting the sale or transfer of the EpiPens. The form also includes instructions for ordering the EpiPens and safety information regarding their use.

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Click ‘Get Form’ to open the EPI-2016-0317 CERTIFICATION FORM in the editor.
Begin by entering the School/School District Name and Address in the designated fields. Ensure all information is accurate as it will be verified.
In the Quantity Ordered section, specify how many EpiPen 2-Pak and/or EpiPen Jr 2-Pak cartons you wish to order. Remember, the total must not exceed two 2-Pak cartons per school.
Fill in the Authorized School Signatory Name, Title, Email, and provide a signature along with the date at the bottom of the form.
Review all entries for accuracy before submitting. Once completed, fax or email your form as instructed at the end of the document.

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EPI-2016-0317 CERTIFICATION FORM: Free ... - RxAssist-2026

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