Parent/Guardian Authorization of Medication at School

ALLERGY PACKET

Student’s Name

Teacher/Grade

Date Sent

Parents,

I have sent you this packet because you have indicated an Anaphylaxis/Allergy history for your child upon this year’s registration or a previous registration.

Additionally, AISD requires all student medications must kept in the Health Office at school.

You will most likely get a packet similar to this annually in order for the school to keep an updated record of your child’s current condition.

Please complete all the documents and return them to the Health Office at school. The last page is required to be completed and signed by the prescribing Physician.

Your child’s health is our priority. Thank you for your attention.

Please feel free to contact me for any questions or concerns.

Tarren Kingsley, RN

School Nurse

Kiker Health Office 512-414-5359

Cell Phone 512-968-1008

Anaphylaxis/Allergic

Reaction Information from Parent

Student Name______Birth Date______School Kiker Elementary

Teacher/grade______Student ID ______Bus #

Parent/Guardian______Phone (H)______Phone(W)______Phone(Cell)

Parent/Guardian______Phone (H)______Phone(W)______Phone(Cell)

Emergency contact______Relationship______Phone

Physician/Clinic______Phone(office)______FAX

Does your child see another doctor/clinic for anaphylaxis/allergic reaction? (If yes, please complete doctor information)? □Yes □No

Doctor/Clinic______Phone(office) FAX

List all medications: Home

School

What date did you child have their first anaphylactic/allergic reaction?

How many anaphylactic/allergic reactions has your child had since the first reaction?

When was your child’s last anaphylactic/allergic reaction?

Has your child been hospitalized due to an allergic/anaphylaxis reaction? □Yes □No Gets to/from school by… □Walking □Car □Bus

Does your child have an Epinephrine auto- injector? □Yes □No Does your child have asthma? □Yes □No

What triggers an anaphylaxis/allergic reaction in your child? (Check all that apply)

Describe the symptoms your child experiences before or during an anaphylaxis/allergic reaction. (Check all that apply)

□ Complaint of tingling, itchiness, □ Swelling/itching of the □ Other______

or metallic taste in the mouth mouth or throat area

Authorization for Release of Medical Information:

I hereby authorize______to furnish anaphylaxis/allergic reaction related information (Clinic/Provider)

regarding my child ______to the Student Heath Services personnel at Kiker Elementary .

Student’s Name School

______

Parent/Guardian Signature Print Name Date

I give permission for the school nurse to communicate with my child’s doctor concerning their anaphylaxis/allergic reaction and its treatment

______

Parent/Guardian Signature Print Name Date

Form is in compliance with SB27

STUDENT SPECIFIC

LIFE THREATENING ALLERGY

EMERGENCY PLAN

Student’s Name: D.O.B. Teacher/Grade:

Student has a history of a previous anaphylaxis allergic reaction [ ] YES [ ] NO

ALLERGY TO:

Asthmatic [ ] YES**Higher risk for severe reaction [ ] NO

Student-assigned epinephrine at school? [ ]YES [ ]NO Location of epinephrine: ______

Complete this form using the physician orders and parent information/authorization

If at school: Send to health room with an adult at first knowledge of allergen exposure. The school nurse will assess the student and decide what actions are needed.

If the school nurse is unavailable, the following staff members are trained to deal with an emergency at school, and to initiate the emergency plan:

______

Parent/relation: Phone#

Parent/relation: Phone#

Emergency Contact/relation: Phone#

Physician: Phone#

Campus RN: RN Contact # Date:

(BENEDRYL or ANTIHISTIMINE)

Elementary Parent/Guardian Authorization of Medication at School

(Complete one form for each medication)

Student Name: Birth Date: Student ID #______

School Name: Kiker Elementary Teacher: Grade: .

Only those medications that are medically necessary during school hours for a student’s attendance or written in an IEP should be sent to school. Children’s AISD Student Health Services and AISD require the following:

·  Parent/Guardian written authorization for medication administration at school

·  Medication in the original, properly labeled container (name of medicine with strength, dosage and directions; name of prescribing physician who is licensed in Texas; current date)

·  Medication label contains the student’s first and last name

·  Non-prescription medication dosage must agree with manufacturer’s recommendations or a physician’s order will be required.

·  The first dose of this medication for the current condition/illness may not be given at school .

Please complete the following:

Dosage

Medication Start Date: Medication Stop Date:

(Note: the first dose of any medication may NOT be given at school)

Has the student ever received this medication before? Yes ______No ______

If Yes, Date and Time last dose given ______

1.  I request that the above medication be given during school hours as ordered by this student’s physician. I also request that the medication be given on field trips, as prescribed with adequate notification from me.

2.  I release school personnel from liability in the event adverse reactions result from taking the medication.

3.  I will notify the school of any change in the medication, (dosage change, time change, etc.).

4.  I give permission for the school nurse to communicate with the student’s teachers about the student’s health condition(s) and the action(s) of the medication.

5.  I give permission for the school nurse to consult with the above student’s physician regarding any questions that arise with regard to the listed medication or medical condition being treated by the medication.

6.  I give permission for the medication to be given by trained school personnel as delegated by the Principal.

Please Note: Elementary school students may not carry medication home (with the exception of inhalers); all medication must be transferred from adult to adult.

I understand I am responsible for retrieving the medication from the School Health Office when it is no longer needed or when the school year ends.

______

Parent/Guardian Printed Name Day Phone Home Phone

______

Parent/Guardian Signature Date Relationship to Student

Copies of this form may be found at: http://archive.austinisd.org/schools/health/ under +Forms.

(EPINEPHRINE)

Elementary Parent/Guardian Authorization of Medication at School

(Complete one form for each medication)

Student Name: Birth Date: Student ID #______

School Name: Kiker Elementary Teacher: Grade: .

Only those medications that are medically necessary during school hours for a student’s attendance or written in an IEP should be sent to school. Children’s AISD Student Health Services and AISD require the following:

·  Parent/Guardian written authorization for medication administration at school

·  Medication in the original, properly labeled container (name of medicine with strength, dosage and directions; name of prescribing physician who is licensed in Texas; current date)

·  Medication label contains the student’s first and last name

·  Non-prescription medication dosage must agree with manufacturer’s recommendations or a physician’s order will be required.

·  The first dose of this medication for the current condition/illness may not be given at school .

Please complete the following:

Medication Start Date: Medication Stop Date:

(Note: the first dose of any medication may NOT be given at school)

Has the student ever received this medication before? Yes ______No ______

If Yes, Date and Time last dose given ______

7.  I request that the above medication be given during school hours as ordered by this student’s physician. I also request that the medication be given on field trips, as prescribed with adequate notification from me.

8.  I release school personnel from liability in the event adverse reactions result from taking the medication.

9.  I will notify the school of any change in the medication, (dosage change, time change, etc.).

10.  I give permission for the school nurse to communicate with the student’s teachers about the student’s health condition(s) and the action(s) of the medication.

11.  I give permission for the school nurse to consult with the above student’s physician regarding any questions that arise with regard to the listed medication or medical condition being treated by the medication.

12.  I give permission for the medication to be given by trained school personnel as delegated by the Principal.

Please Note: Elementary school students may not carry medication home (with the exception of inhalers); all medication must be transferred from adult to adult.

I understand I am responsible for retrieving the medication from the School Health Office when it is no longer needed or when the school year ends.

______

Parent/Guardian Printed Name Day Phone Home Phone

______

Parent/Guardian Signature Date Relationship to Student

Copies of this form may be found at: http://archive.austinisd.org/schools/health/ under +Forms.

ALLERGY AND ANAPHYLAXIS PHYSICIAN ORDERS

Name: D.O.B.

Allergy to: ______

Weight: _____lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No

Note: Do not depend on antihistamines or inhalers (broncodilators) to treat a severe reaction. USE EPINEPHRINE.

PARENT / GUARDIAN SIGANTURE DATE PHYSICIAN / HCP SIGNATURE DATE

Dell Children’s Medical Center of Central Texas | Children’s/AISD Student Health Services

4900 Mueller Boulevard, Austin, Texas 78723 | P (512) 324-0195 | F (512) 406-6543 | www.dellchildren.net