NAVASOTA ISD MEDICATION AUTHORIZATION FORM

In accordance with Section 22.052 of the Texas Education Code, a Navasota ISD School Nurse, Nurse Assistant, Medical Assistant or employee designated by the campus principal may administer medication to students in accordance with the District policy and regulations listed below:

1)  A Medication Authorization form must be completed & signed every time medication is sent to school.

2)  All Medication (prescription/ non-prescription) must be in the original, properly labeled container. The prescription medication pharmacy label must include:

A)  Name of Student

B)  Name of Physician

C)  Date of Prescription

D)  Directions for use/dosage and frequency

E)  Name of Medication

3)  Nonprescription medication to be administered for more than 10 calendar days ( i.e., the entire school year) must be accompanied by a doctor’s order.

4)  All medication must be kept in locked storage in the campus clinic.

5)  Medication dosage will not be changed without an order from the physician. If a district employee has questions about the administration of a medication, the employee shall contact the parents or physician.

Print Student’s Name / Grade / Date of birth
Physician / Physician’s Phone Number / Allergies
Medication / Dosage / Time(S) / Comments
Notes:______
______
______
This information may be shared with my child’s teachers and with staff who have a need to know about the medication. I give my permission
for you to contact the above named physician to clarify questions concerning dosage and times of administration.
______
Parent/Guardian’s Signature Daytime Phone Number Date

It is the policy of the Navasota Independent School District not to discriminate on the basis of race, color, sex, age, national origin, religion, handicap, or disability in its employment practices as required by Title IV of the Civil Rights Act of 1975, as amended, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, as amended, Section 504 of the Rehabilitation Act of 1973 as amended & the Americans with Disabilities Act of 1992.

Revised 2009