Code No. 507.2E1

 

AUTHORIZATION - ASTHMA, AIRWAY CONSTRICTING OR RESPIRATORY DISTRESS MEDICATION SELF-ADMINISTRATION CONSENT FORM

 

_____________________________           ___/___/___                 _________________ ___/___/___

Student’s Name (Last), (First)  (Middle)     Birthday                        School       Date

 

In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency.  The following must occur for a student to self-administer asthma medication, bronchodilator canisters or spacers, other airway constructing disease mediation or to self-administer an epinephrine auto-injector:

• Parent/guardian provides signed, dated authorization for student medication self-administration.

• Parent/guardian provides written statement from the student’s licensed health care professional  (A person licensed under chapter 148to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner under chapter 152 or 152E and registered with the board of nursing or a physician assistant licensed to practice under the supervision of a physician as authorized in chapters 147 and 148C)containing the following:

  • name and purpose of the medication, 

  • prescribed dosage, and

  • times or special circumstances under which the prescribed medication is to be administered

  • The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student’s name, name of the medication, directions for use, and date.

  • Authorization shall be renewed annually.  If any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.

Provided the above requirements are fulfilled, the school shall permit the self-administration of the prescribed medication by a student with asthma, respiratory distress or other airway constricting disease or the use of an epinephrine auto-injector by a student with a risk of anaphylaxis while in school, at school district sponsored activities, under the supervision of school district personnel, and before or after normal school activities, such as while in before-school or after-school care on school operated property. If the student abuses the self-administration policy, the ability to self- administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

Pursuant to state law, the school district and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine auto-injector by the student as provided by law.

 

AUTHORIZATION - ASTHMA, AIRWAY CONSTRICTING OR RESPIRATORY DISTRESS MEDICATION SELF-ADMINISTRATION CONSENT FORM

___________________          _____________        __________________________________           __________

Medication                                 Dosage                        Route                                                                       Time

___________________________________________________________________________________________

Purpose of Medication and Administration /Instructions

___________________________________________         ________________________

Special Circumstances                                                                 Discontinue/Re-Evaluate/Follow-up Date

____________________________                                        ____________

Prescriber’s Signature                                                                 Date

____________________________                                        ________________               

Prescriber’s Address    Emergency Phone

• I request the above-named student possess and self-administer asthma medication, bronchodilators, canisters or spacers or other airway constricting disease medication(s) and/or an epinephrine auto-injector at school and in school district activities according to the authorization and instructions. 

• I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or an epinephrine auto-injector or for supervising, monitoring or interfering with a student's self-administration of medication or use of an epinephrine auto-injector.  I acknowledge that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or use of an epinephrine auto-injector by the student.

• I agree to coordinate and work with school district personnel and notify them when questions arise or relevant conditions change.

• I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment. 

• I agree the information is shared with school district personnel in accordance with the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. 

• I agree to provide the school with back-up medication approved in this form.

• Student maintains self-administration record.

__________________________________                   ______________

Parent/Guardian Signature                                                  Date

(agreed to above statement)

_________________________________                     _______________

Parent/Guardian Address                                                   Home Phone

  _________________

Business Phone

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Self-Administration Authorization Additional Information

 

 

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION TO STUDENTS

 

_____________________________       ___/___/___            _________________     ___/___/___
Student's Name (Last), (First)  (Middle)      Birthday                    School                                   Date

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer medication and/or provide special health service listed.  Electronic signatures meet the requirement of written signature.
• The prescribed medication is in the original, labeled container as dispensed..
• The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

                                                                                                                                             _________  
Prescribed Medication                   Dosage                         Route                           Time at School

Special Health Services and instructions, in indicated:

                                                                                                                                               

                                                                                                                                              

________________________________________________________

________________________________________________________

 

            /           /          
Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services listed.

                                                                                                             /           /           
Prescriber’s Signature and credentials                               Date

(when indicated for health service deliver)

                                                                                                            /            /          
Parent's Signature                                                            Date

                                                                                                                                   
Parent's Address                                                              Home Phone

                                                                                                                                   
Additional Information                                                  Business Phone

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               
Authorization Form

 

PARENTAL AUTHORIZATION AND RELEASE FORM FOR INDEPENDENT SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE STUDENT

____________________________________ / /   ___________________ ____/____/_____

Student's Name (Last), (First), (Middle)                        Birthday                           School                             Date

I request the above-named student (Parent/Guardian initial all that apply)

______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency.  The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.  I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

_________________________ ______________ __________________ ________________________

Prescribed Medication                       Dosage Route                                    Time at School

______ Co-administer, participate in planning, management and implementation of special health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school. The information provided by the parent for health service delivery is confidential as provide by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.  I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise.  I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year. 

Special Health Services Delivery:

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

Procedures for abandoned medication disposal shall be in accordance with applicable laws.

___________________________ ________________

Prescriber’s Signature  Date

and credentials (when indicated for health service delivery)

____________________________ ________________

Parent/Guardian Signature                                             Date

____________________________ __________________

Parent/Guardian Address                                             Home phone

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF VOLUNTARY SCHOOL STOCK OF OVER-THE-COUNTER MEDICATION TO STUDENTS

 

________________________________ __/___/___ ___________ ___/___/___

Student's Name (Last), (First), (Middle) Birthday School Date

The district supplies the following nonprescription, over-the-counter medications that are listed below. Generic brands may be substituted, (select all that apply):

• Acetaminophen administered per manufacturer label

• Throat Lozenges administered per manufacturer label

• Ibuprofen administered per manufacturer label 

Voluntary school stock of nonprescription, over-the-counter medications are administered following these guidelines:

• Parent has provided a signed, dated annual authorization to administer the nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature.

• The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.

• All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the counter medication. 

• Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOTapplicable. 

• Nonprescription, over-the-counter medications approved by the Federal Drug Administration that require emergency medical service (EMS) notification after administration are NOT applicable.

• Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the department and annual medication administration procedural skills check.

  • Districts stocking the administration of a voluntary stock of nonprescription, over-the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:

    • when to contact the parent when a nonprescription medication, over the counter medication is administered;

    • documentation of the administration of the nonprescription, over-the-counter medication and parent contact;

    • a limit to the administration of a school’s stock nonprescription, over-the-counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school year;

    • the development of an individual health plan for ongoing medication administration or health service delivery at school.

I request that the above-named student receive the voluntary stock nonprescription, over-the-counter medications supplied by the school in accordance with the district guidelines and protocol.

__________________________________________        _________________________

Parent Signature                                                                  Date

__________________________________________        ________________________

Parent/Guardian Address                                                    Home Phone