504.31-E4 - Parent/Guardian Authorization and Release Form for Administration of Voluntary School Stock of Over-the-Counter Medication to Students

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)