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1. Where did the event take place?
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2. Date of incident
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3. Date of report
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4. Age of person with allergic reaction
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5. What caused the allergic reaction?
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6. Symptoms of the allergic reaction
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7. Was the facility's auto-injector used or the person's own auto-injector?
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8. Was more than one dose required?
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9. Was 911 called?
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10. Did the person go to the emergency room?
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11. What was the outcome of this incident?
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