Today’s Date. 1 0 obj However, many students with mild acute and chronic health conditions need access to medications at school in order to enhance their overall health, stabilize their condition, and promote and support their … Prescription Medication must be registered with School Nurse or trained Medication Assistants. The form must be signed by a parent/legal guardian. I give permission for my child's doctor to be contacted for information regarding the administration of the medication listed on this form. • By signing, I give permission for the school nurse and prescribing health care provider to exchange information regarding any necessary medication order clarifications, response to medication, and adverse effects. A new medication administration form must be completed at the beginning of each school year, for each medication, and each time there is a change in dosage or time of administration of a medication. *Prescription medication must be in a container labeled by the pharmacist or prescriber. All state schools Purpose. this request will be based on school health guidelines. The permission is effective for the school year and will be reviewed annually. Written or verbal changes from parent/guardian cannot be accepted. * Prescription medication must be in a container labeled by the pharmacist or prescriber. REQUEST FOR ADMINISTRATION OF MEDICATION, TREATMENTS OR USE OF EQUIPMENT IN SCHOOL DATE OF BIRTH PHYSICIAN, PLEASE NOTE: Fill in all of the spaces. NOTICE TO PARENTS: The parent/legal guardian must bring medication to school. Students may not transport medication to or from school. If your child is to take medications at school, you must fill out the required paperwork. DISCLAIMER: As noted, these forms are supplied by our readers. It is to be completed by the parent or legal guardian and physician. This form must be entirely completed in order for school health staff to administer the required medication. Self-administration of medication may be authorized by the prescriber (when applicable) and school nurse (when applicable) and must be authorized by parent/guardian in accordance with board policy. REQUEST FOR ADMINISTRATION OF MEDICATION. Prescription medication must be properly labeled with student’s name, prescriber’s name, name of medication, dosage, time intervals, route of administration … 4 0 obj Forms to request medication administration at school, for self-administration during the school day, and for self-administration outside school … School medication orders shall be limited to medication that cannot be administered before or after school hours. No medication of any kind will be given to your child until this information is completed and returned to the school. Dr. Martin Luther King Jr. Day: Schools Closed SECTION A: Section A is to be completed by the parent or legal guardian. printable version. DIABETES MEDICATION ADMINISTRATION FORM [PART A] Provider Medication Order Form – Office of School Health – School Year 2020-2021 Forms submitted after June 1st may delay processing for new school year. Text fields, radio buttons, formatted addresses and phone numbers, dates, times, signatures—every format you need is at your fingertips. A Health Care Provider’s signature is required. This publication contains forms for schools to download. Parents and Health Services staff work together to provide safe medication administration to students, if needed, during the school day. Training and supervision of UAPs who administer medications should be done by the school nurse, and consideration of safety and school nurse workload is essential. Examination Results; Leaver Destinations. Signature of Parent or Guardian Date Forms. This policy statement is designed to guide prescribing physicians as well as school administrators and health staff on the administration of medications to children at school. in a container that is appropriately labeled by the pharmacy or physician. Sixth Form Applications for 2021 Entry. to be given 3 times a day, you should give it before school, right after school, and at bedtime. Once a Medication Administration Authorization form is completed by the parent, student and health care provider indicating the need for the student to self-carry a medication is on file at the school, the student may carry the following medications: Missing information will cause the form to be returned to you. NPS Health Services - Revised July 2016 Page 1 of 2 . It will be valid for the current school year or until a discontinuing date listed by the prescribing individual. However, if medication is necessary during the school day, there are guidelines that must be followed to keep your student safe. General Medication Administration Form (School Year 2020 - 2021) Arabic , Bengali , Chinese , English , French , Haitian Creole , Korean , Russian , Spanish , Urdu Request for the Provision of Medically Prescribed Treatment (Non-Medication) for School Year 2020 - 2021 They are likely not suitable for all cases, schools, districts, etc. FORM 1 SCHOOL NAME: _____ AUTHORIZATION FOR ADMINISTRATION OF MEDICATION ... Parent/guardians must complete the Authorization for Administration of Medication Form (Form 1) when a child requires medication but does not require additional support(s) accommodations or assistance. I authorize the above medication to be administered as described or prescribed during school or after-school programs operated by Collier County Public Schools. I shall indemnify and hold harmless the school, the agents of the school, and the local board of education against any claims that may arise relating to my child’s self-administration of prescribed medication(s). A new medication administration form must be completed at the beginning of each school year, for each medication, and each time there is a change in dosage or time of administration of a medication. This form is accepted by all public schools in Chesapeake, Norfolk, Portsmouth,Suffolk, and Virginia Beach . We are happy to provide a convenient online source for reviewing and/or downloading. Medication Administration Forms. UCAS and Careers Information . School: _____ This form must be completed fully in order for schools to administer the required medication. If your child is to take medications at school, you must fill out the required paperwork. Physician Authorization for Medication Form References: California Education Code Section: 49423 Medication at School; 49480 Continuing Medication. Please respond to every item on this form. Student Last Name MaleFirst Name . endobj Also if your child is given medication throughout the year (antibiotics, eardrops, etc.) SCHOOL MEDICATION ADMINISTRATION AUTHORIZATION FORM This order is valid only for school year (current) _____ including the summer session. Emergency Management FormsSchool to EMS/Hospital Transfer Sheet, Head LiceLice PolicyHead Lice Tracking Form - Family Unit Head Lice Tracking Form - Individual Child, Health Room Visit Forms Clinic PassClinic Pass (2)Clinic Visit Front Side Clinic Visit Reverse Side Health Office Log - General, Medication Administration Forms Agreement to Carry Epinephrine at School Authorization to Administer Medication at School Authorization to Administer Medication at School - 2 Authorization to Self Carry Medications Contract for Self Carried Medications Medication Administration Skills Checklist Medication Log Medication LOG - PRN Meds OTC Medication Request Form Sample Medication Administration Daily Log Permission to Carry EpiPen® at School, Nurse Activity Reports Anaphylaxis Incident Form, Physician Contact/letters Adaptive Physical Ed Physician Form G-Tube - Doctor orders, Release Forms HIPAA Compliant Release of Records Form, HIPAA Compliant Release of Records Form (2), School Nurse Management Forms Back to School Checklist Kindergarden Work Sheet Managing the Needs of Students with Chronic Diseases in a School Emergency School Nurse Monthly Activities Report, Seizures Seizure Intake Form Seizure Plan, Head Lice Tracking Form - Individual Child, Authorization to Administer Medication at School, Authorization to Administer Medication at School - 2, Medications Medication Administration Skills Checklist, Sample Medication Administration Daily Log, Managing the Needs of Students with Chronic Diseases in a School Emergency.