CLICK HERE TO DOWNLOAD THE PARENT/GUARDIAN AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION OR SPECIAL HEALTH SERVICESTO STUDENTS

Student’s Name (Last, first, middle): ___________________________________________________________

Birthday: _________________________ School: ______________________ Date: _____________________

School medications and special health services are administered following these guidelines:

1. Parent/guardian has provided a signed, dated authorization to administer prescription medication and/or provide special health services listed. Electronic signatures meet the requirement of written signatures.
2. The prescribed medication is in the original, labeled container as dispensed.
3. 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.
4. Authorization is renewed annually and as soon as practical when the parent/guardian notifies the school that changes are necessary.

Prescribed Medication: ______________________________________ Dosage: ________________________

Route: _______________________________________________ Time at School: _____________________

Special health services and instructions, if indicated: _________________________________________________

_____________________________________________________________________________________
Discontinue/Re-Evaluate/Follow-Up Date for prescribed medication or special health services listed.

Prescriber’s Signature: _____________________________________________ Date: _____________

Prescriber’s Credentials (when indicated for health service delivery): _______________________________

Parent/Guardian Signature: ___________________________________________ Date: __________________

Parent/Guardian Address: ________________________________________ Phone: ____________________

Additional Information: ___________________________________________________________________

Reviewed: 7/13; 12/20
Revised: 10/14; 4/16; 10/17; 6/20; 8/21; 8/23
Related Policy: 504.31; 504.31-E2; 504.32
IASB Reference: 504.07-E(2)

CLICK HERE TO DOWNLOAD THE AUTHORIZATION-ASTHMA, AIRWAY CONSTRICTING, OR
RESPIRATORY DISTRESS MEDICATION SELF-ADMINISTRATION CONSENT FORM

Student 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 parent/guardian 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 constricting disease medication, or to self-administer an epinephrine auto-injector:

1. Parent/guardian provides a signed/dated copy of the authorization for student medication self-administration;
2. Parent/guardian provides a written statement from the student’s licensed health care professional (A person licensed under Chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under Chapter 152 or 152E and registered with the Board of Nursing, or a physician’s assistant licensed to practice under the supervision of a physician as authorized in Chapters 147 and 148C) containing the following:
   1. Name and purpose of the medication;
   2. Prescribed dosage; and
   3. Times or special circumstances under which the prescribed medication is to be administered.
3. 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; and
4. Authorization shall be renewed annually. In addition, if any changes occur in the medication, dosage or time of administration, the parent/guardian 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 while in school, at school-sponsored activities, under the supervision of school 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/guardian.

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

PRESCRIBER INFORMATION
Medication:
Dosage:
Route:
Time:
Purpose for Medication and Administration/Instructions:
Special Circumstances:
Discontinue/Re-Evaluate/Follow-Up Date:
Prescriber's Signature:
Date:
Prescriber's Address:
Emergency Phone:

1. I request the above-named student possess and self-administer asthma medication, bronchodilator canisters or spacers, or other airway constricting disease medication(s) and/or an epinephrine auto-injector at school and in school activities according to the authorization and instructions;
2. 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;
3. I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change;
4. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment;
5. I agree the information shared with school personnel in accordance with the Family Educational Rights and Privacy Act (FERPA) and any other applicable laws;
6. I agree to provide the school with back-up medication approved on this form; and
7. I agree that the student will maintain their own self-administration records.

Parent/Guardian Signature:
Date:
Address:
Home Phone:
Cell Phone:
Work Phone:
Self-Administration Authorization Additional Information:

Adopted: 4/16
Reviewed: 11/17; 12/20
Revised: 3/23; 8/23
Related Policy: 504.31; 504.31-E1; 504.32
IASB Reference: 507.02-E(1)

CLICK HERE TO DOWNLOAD THE PARENT/GUARDIAN 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:
Building:
Date:

I request the above-named student: (Parent/guardian initial below all that apply)

CLICK HERE TO DOWNLOAD PARENT/GUARDIAN AUTHORIZATION AND RELEASE FORM FOR ADMINISTRATION OF VOLUNTARY SCHOOL STOCK OF OVER-THE-COUNTER MEDICATION TO STUDENTS

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

• Acetaminophen administered per manufacturer label
• Ibuprofen administered per manufacturer label

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

1. Parent/guardian has provided a signed, dated annual authorization to administer of the nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature.
2. The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.
3. All other nonprescription, over-the-counter medication not listed will require a written parent/guardian authorization and supply for the over-the-counter medication.
4. Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration (FDA) and are NOT applicable.
5. Nonprescription, over-the-counter medications approved by the FDA that require emergency medical service (EMS) notification after administration are NOT applicable.
6. 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/guardian to define at a minimum:
     • When to contact the parent/guardian when a nonprescription medication, over-the-counter medication is administered;
     • Documentation of the administration of the nonprescription, over-the-counter medication and parent/guardian 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; and
     • The development of an Individual Health Plan (IHP) for ongoing medication administration or health service delivery at school.

I request 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/Guardian Signature:
Date:
Address:
Phone:

Adopted: 8/23
Related Policy: 504.31; 504.31-E1-E3
IASB Reference: 507.02-E(4)