For ALL Prescription Or Over-The-Counter Medications Administered at School

For ALL Prescription Or Over-The-Counter Medications Administered at School

Health Services Department – Bremerton School District 100-C

134 Marion Avenue North

Bremerton, WA 98312-3542

Office: 360.473.1073 Fax: 360.473.1043

Web:

MEDICATION AUTHORIZATION FORM

for ALL prescription or over-the-counter medications administered at school

School: ______Year: ______School Fax #: ______

This section must be completed by the PARENT / GUARDIAN: (please print)

Student: ______DOB: ______Grade: _____ M/F
I request/authorize the school to administer the identified medication to the above student. I understand that:
  • I will furnish medication(s) in original container and pick it up on the last day of school

  • I will monitor expiration date of medication(s)

______Date: ______Phone: ______
Parent / Guardian / Student signature:
Medication(s) requested:
Health Care Provider: Phone & Fax
□ I give my permission for exchange of information between the School Nurse and the Health Care Provider.
Please check only one box:
□ I request that the authorized persons at school assist my child in taking the medicine(s) described below.
□ I request that my child be allowed to self-administer medication. I shall hold harmless and indemnify the school and Bremerton School District’s officers, employees and agents against all claims, judgments, or liabilities arising out of the self-administration and carrying of medication by the above-named child.
□ I am signing this form on my own behalf (RCW 26.28.015 or RCW 70.02.130)

This section to be completed by the Health Care Provider: (MD, DO, ND, DMD, DC, PA, ARNP or CNM)

MEDICATION #1MEDICATION #2

Medication / strength:
Tablet / Capsule / Liquid Inhaler / Injection / Other
Reason / Diagnosis:
Dose:
Time of dose:
Side effects:
How soon can it be repeated?
Student capable to carry and safely administer without supervision
□ Yes – Instructions given to student □ No – may not self-carry /administer
□ Yes – Instructions given to student □ No – may not self-carry /administer
*Checking “Yes” indicates that student has been instructed in the purpose and appropriate method/frequency of use.
Medication authorized for these dates: School Year: Other:
School Year: Other:
I request that the above named student be administered the above medication in accordance with the instructions indicated, as there exists a valid health reason which makes administration advisable during school hours.
Health Care Providers signature: Date: Phone:
Print or Stamp Name

Policy #3416

Medication at School

Under normal circumstances prescribed oral medication and oral over the counter medication should be dispensed before and/or after school hours under supervision of the parent or guardian.

If it is essential for a child to take oral medication during school hours and the parent cannot be at school to administer the medication, the parent must submit a written authorization accompanied by written instructions from a licensed health professional prescribing within the scope of his or her prescriptive authority.

The Superintendent shall establish guidelines for:

  1. Training and supervision of staff members in the administration of prescribed or non-prescribed oral medication to students by a physician or registered nurse;
  2. designating staff members who may administer prescribed or non-prescribed oral medication to students;
  3. obtaining signed and dated parental and health professional request for the dispensing of prescribed or non-prescribed oral medication, including instructions from the health professional if the medication is to be given for more than fifteen days;
  4. storing prescribed or non-prescribed medication in a locked or limited access facility and
  5. Maintaining records pertaining to the administration of prescribed or non-prescribed oral medication.

No medication shall be administered by injection except when a student is susceptible to a predetermined, life endangering situation. In such an instance, the parent shall submit a written and signed permission statement. Such an authorization shall be supported by signed and dated written orders accompanied by supporting directions from the health care professional. A staff member shall be trained prior to injecting a medication.

Legal Reference: RCW 28A.210.260 Public and private schools--Administration of oral medication by--Conditions

28A.210.270 Administration of oral medication by Immunity from liability

Attorney General Memorandum 2/9/89

Bremerton School District Adopted: / 11/17/83
Revised: / 10/19/00
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