Policy Code: JGCDA Self Administration and Self Carry of Asthma and Anaphylaxis Medication

Section:JStudents

Policy Code: JGCDA Self Administration and Self Carry of Asthma and Anaphylaxis Medication

Policy:

The safety and well-being of students is of utmost importance to the Ocean Springs School Board, the administration, teachers and staff. The school board shall permit the self-administration and self carry of asthma and anaphylaxis medications by a student if the student’s parent or guardian:

Provides written authorization from the student’s parent or guardian for self administration and self carry of asthma and/or anaphylaxis medications to the school; and,
Provides written authorization in which the student’s parent or guardian releases Ocean Springs School District and its employees and agents from liability for an injury arising from the student’s self administration or asthma and/or anaphylaxis medication. And that the student’s parent or guardian shall indemnify and hold harmless the school and its employees against any claims relating to the self administration of asthma and/or anaphylaxis medication.
Provides a written authorization from the student’s health care practitioner that the student has asthma and/or an allergy that is at risk for anaphylaxis.
Provides a written authorization from the student’s health care practitioner that the student has been instructed in self administration of the prescribed asthma and/or anaphylaxis medications.
Provides a written authorization from the student’s health care practitioner that the student possesses the knowledge and is capable of self-administering the prescribed asthma and/or anaphylaxis medication.
Provides Exhibit JGCD-E(1) Ocean Springs School District Medication Permission Request Form completed by both the student’s parent or guardian and the student’s health care practitioner. Exhibit JGCD-E(1) shall contain the following information:
The name and purpose of the medication;
The prescribed dosage;
The time or times the medications are to be administered and under what additional special circumstances the medications are to be administered; and
The length of time for which the medication is prescribed.
If the student uses Ocean Springs School District transportation, provides a completed asthma transportation plan and/ or a severe allergy transportation plan with written authorization from the student’s parent or guardian.

The statements required as listed above shall be kept on file in the office of the school nurse or the school principal or his/her designee.

The statements required as listed above shall be effective for the school year in which it is granted and shall be renewed each following school year upon fulfilling the requirements as stated in this policy.

Upon fulfilling the requirements as stated in this policy, a student with asthma and/or an allergy that is at risk for anaphylaxis may possess and use asthma and/or anaphylaxis medications when at school, at a school sponsored activity, under the supervision of school personnel or before and after normal school activities while on school properties including school sponsored child care or after-school programs.

Students may be subjected to discipline in accordance with other district policies for misuse of any asthma and/or anaphylaxis medication, distribution or sale of any asthma and/or anaphylaxis medication, allowing another student to use any asthma and/or anaphylaxis medication, or use of any asthma and/or anaphylaxis medication in any manner not prescribed by the student’s health care provider.

INDEMNIFICATION

Ocean Springs School District shall inform the parent or guardian of the student that the school and its employees and agents shall incur no liability as a result of any injury sustained by the student from the self administration of asthma and/or anaphylaxis medications. The parent or guardian of the student shall sign a written statement acknowledging that the school shall incur no liability and the parent or guardian of the student shall indemnify and hold harmless the school and its employees against any claims relating to the self administration or asthma medications.

Definitions

“Asthma and/or anaphylaxis medication” means inhaled bronchodilator and auto-injectable epinephrine.
“Self administration or prescribed asthma and/or anaphylaxis medication” means a student’s discretionary use of prescription asthma and/or anaphylaxis medication.

LEGAL REFERENCE

Senate Bill 2218, 2014 Mississippi Legislative Session

OCEAN SPRINGS SCHOOL DISTRICT

PARENTAUTHORIZATION FOR SELF ADMINISTRATION OF ASTHMA OR ANAPHLAXIS MEDICATION

BY STUDENTS IN THE OCEAN SPRINGS SCHOOL DISTRICT.

I/We, the undersigned parent/s or guardian/s of ______name of student, authorizes the school/school district to permit my/our child to self-administer asthma or anaphylaxis medication. I/We understand that a written statement must accompany this authorization from my/our child’s health care practitioner verifying the following:

The student has asthma or an allergy that is at risk for anaphylaxis.
The student has been instructed in self administration of asthma or anaphylaxis medication.
The student possess the knowledge and capability of self-administering the asthma or anaphylaxis medication.
Exhibit JGCD-E(1) Ocean Springs School District Medication Permission Request Form completed by both the student’s parent/s or guardian/s and the student’s health care practitioner. Exhibit JGCD-E(1) Shall contain the following information:
The name and purpose of the medication;
The prescribed dosage;
The time or times the medication are to be administered and under what additional special circumstances the medication are to be administered; and
The length of time for which the medication is prescribed.

RELEASE AND INDEMNITY AGREEMENT

I/We forever release, discharge, and covenant to hold harmless the Ocean Springs School District, its personnel and Board of Trustees form any and all claims, demands, damages, expenses, loss of services and causes of action belonging to my/our child or the undersigned arising out of or on account of any injury, sickness, disability, loss or damages of any kind resulting from self administration of the asthma or anaphylaxis medicines.

I/We agree to repay the school district, its personnel or trustees any sum or money, expenses, or attorney’s fees that any of them may be compelled to pay in defense of any action or on account of any such injury to my/our child as a result of self administration of the asthma or anaphylaxis medicines.

I/We understand that any child may be subjected to discipline in accordance with other district policies for misuse of any asthma or anaphylaxis medication, distribution or sale of any asthma or anaphylaxis medication, allowing another student to use any asthma or anaphylaxis medication, or use of any asthma or anaphylaxis medication in any manner not prescribed by the student’s health care practitioner.

I/We have read the foregoing release and indemnity agreement and fully understand it.

Executed this the ______day of ______, 20___.

______

Parent or Guardian SignatureWitness Signature

Work Phone: ______Home Phone: ______

Cell Phone: ______

Contact Person Other Than Parent: ______

Work Phone: ______Home Phone: ______

Cell Phone: ______

OCEAN SPRINGS SCHOOL DISTRICT

PHYSICIAN AUTHORIZATION FOR SELF ADMINISTRATION OF ASTHMA OR ANAPHLAXIS MEDICATION

BY STUDENTS IN THE OCEAN SPRINGS SCHOOL DISTRICT.

*Use a separate authorization from for each medication*

Date: ______

Student’s Name: (First/Last): ______

School: ______Student’s Date of Birth: ______

TO BE COMPLETED BY STUDENT’S LICENSED HEALTH CARE PROVIDER:

Diagnosis: ______

Medication Name: ______

Medication Dose: ______

Medication Time to be Given: ______

Length of Time Medication is to be Given: ______

Additional Medication Information: ______

______

(___) I, the student’s health care provider, have instructed ______on the proper way to use the above medication. He/She possess the knowledge and are capable of self administration of the above medication. It is my professional opinion that he/she should be allowed to self carry and self-administer the above medication.

(___) It is my professional opinion that ______should NOT be allowed to self carry or self-administer the above medication by him/herself.

Comments: ______

______

Licensed Health Care Provider SignatureDate

______

Licensed Health Care Providers Phone Number

______

Parent/Guardian SignatureDate

Ocean Springs School District JGCD-E(1)

Medication/Procedures Permission Request Form

STUDENT NAME: ______DATE OF BIRTH:______

MEDICATION ALLERGIES: ______

SCHOOL :______TEACHER/GRADE:______

The Ocean Springs School District requires that all students who require prescription or non-prescription medication or special health procedures during school hours must do the following:

1.Present a written consent form signed by the parent, or legal guardian and completed by a physician to the principal or designee.

2.Bring the medication in the original prescription bottle, properly labeled by a legally registered pharmacist. Give it to the school official who will be responsible for administering the medication to your child. Over-the-counter medication is to be provided by the parent/guardian and brought to the principal or designee in the original container with the child’s name clearly labeled on the container.

3.All procedures required during the school day must have a completed permission form stating type of procedure, supplies needed and time to perform.

Medication may be given by the designated school official provided that the prescribing physician completes the Medication/Procedures Permission Request Form. If there is a change in medication, a new form must be filled out. Contact your school nurse with any changes.

TO BE COMPLETED BY PHYSICIAN
Procedure/Medication & Dose:______
Time to be given at school:______
Length of time to be given:______
Restrictions? Yes No (circle one) If yes, what and how long?______
Print Physician Name:______
Physician Signature:______
Physician’s phone number:______Fax Number:______
Date:______
TO BE COMPLETED BY PARENT/GUARDIAN
I,______, give permission for my child, ______, to
receive the following procedure/medication at school:
Procedure/Medication & Dose:______
Time to be given:______Length of time to be given:______
Parent/guardian signature______
Phone number Home/cell/work_______
e-mail______
Date______

Ocean Springs School District -Severe Allergy Transportation Plan

Plan of action for ______regarding severe allergic reactions and transportation.

The student has a life threatening allergy to: ______

ACTION: STEPS TO TAKE DURING AN ALLERGIC REACTION

The student carries an EpiPen/Auvi-Q on the bus Yes______No______

The EpiPen/Auvi-Q can be found in: Backpack______Waist pack ______Other (specify) ______

The student will sit at front of the bus Yes ______No______

Treatment for MILD Allergic Reaction
Mild Symptoms / Treatment / Call 911 if:
Few Hives
Itchy Skin / Contact parent/guardian or emergency contact person describe student’s symptoms and where you are on the bus route.
Continue the route as usual / Symptoms continue to worsen
Or the student develops symptoms of a life-threatening allergic reaction as listed below.
Treatment for LIFE-THREATENING Allergic Reaction
Life-Threatening Symptoms / Treatment
Hives spreading over the body
Wheezing, high pitched breath sounds
Difficulty swallowing
Difficulty breathing
Swollen face or neck
Tingling or swollen tongue
Vomiting
Extreme paleness or gray colored skin
<First Name> has difficulty walking or talking. / Stop at the nearest school or open area
Administer EpiPen, EpiPen Jr, or Auvi-Q and call 911 for further instructions.
Side Effects: Rapid heartbeat,
Contact the parent/guardian or emergency contact person.
School administrator should accompany the student to the emergency room if the parent/guardian or emergency contact is unavailable.

**If 911 is contacted, the bus driver or aide will contact OSSD Administration and the child’s parent at the numbers listed below: **

I agree with this plan and give permission for school personnel who have been trained in medication administration by the nurse, to administer prescribed medicine and to contact emergency medical services, if necessary. It is the responsibility of the parent to contact the nurse in order to have such medication available for use on the student.

Parent’s Signature: ______Date: ______

Ocean Springs School District: ______Date: ______