Student's Name (Last, First, Middle):
Birthday:
Building:
Date:
I request the above-named student: (Parent/guardian initial below 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 parent/guardian and prescribing licensed health care professional regardless of competency. The information provided by the parent/guardian 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 If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent/guardian.
Prescribed Medication: _______________ Dosage: _________ Route: ___________ Time: ________
_____ 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/guardian for health service delivery is confidential as provided 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 (and credentials when indicated for health service delivery):
Date:
Parent/Guardian Signature:
Date:
Phone:
Address:
Adopted: 8/23
Related Policy: 504.31; 504.31-E1-E2
IASB Reference: 507.02-E(3)