504.31-E2 - Authorization: Asthma, Airway Constricting, or Respiratory Distress Medication Self-Administration Consent Form

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Student Name (Last, First, Middle): _____________________________
Birthday: _______________________
School: _________________________

In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress, or students at risk of anaphylaxis who use an epinephrine delivery system 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 constricting disease medication, or to self-administer an epinephrine delivery system:

  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.
  4. Authorization shall be renewed annually. In addition, 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 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.

Pursuant to state law, the 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 delivery system by the student. The parent or guardian of the student shall sign a statement acknowledging that the district is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine delivery system by the student as provided by law.

This section to be completed by prescriber
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: ___________________

This section to be completed by parent/guardian

  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 delivery system at school and in school activities according to the authorization and instructions;
  2. I understand the district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or an epinephrine delivery system or for supervising, monitoring, or interfering with a student’s self-administration of medication or use of an epinephrine delivery system. I acknowledge that the district is to incur no liability, except for gross negligence, as a result of self-administration of medication or use of an epinephrine delivery system 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 is 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; 9/26
Related Policy: 504.31; 504.31-E1; 504.32
IASB Ref: 507.02-E(1)