507.2E3-Parental Authorization and Release Form for INDEPENDENT SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE

507.2E3-Parental Authorization and Release Form for INDEPENDENT SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE

 

Code No. 507.2E3

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 If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.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

 

Adopted: 8/15/2023

Reviewed: 04/22/2024

Revised: 

bbolsinger@edg… Wed, 09/13/2023 - 15:10
File Attachments
507.2E3-PARENTAL AUTHORIZATION AND RELEASE FORM FOR INDEPENDENT SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE STUDENT.pdf

507.2E4-PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF VOLUNTARY SCHOOL STOCK OF OVER-THE-COUNTER MEDICATION TO STUDENTS

507.2E4-PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF VOLUNTARY SCHOOL STOCK OF OVER-THE-COUNTER MEDICATION TO STUDENTS

Code. No. 507.2E4

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
  • Other: ____________________ administered per manufacturer label (Please Specify)
  • Other: ____________________ administered per manufacturer label (Please Specify)
  • Other: ____________________ administered per manufacturer label (Please Specify)
  • Other: ____________________ administered per manufacturer label (Please Specify)

 

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

  • Parent 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.
  • 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 NOT applicable.
  • 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;

 

Code No. 507.2E4

Page 2 of 2

      • 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                                                                                                                                      

   

 

Adopted: 8/15/2023

Reviewed: 04/22/2024

Revised:

 

bbolsinger@edg… Wed, 09/13/2023 - 15:13
File Attachments
507.2E4-PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION .pdf