Request to Administer Medication at School
The school staff is willing to cooperate with physicians and parents if a child must take medication during school hours. Please note the following guidelines:
- A signed physician’s order is required, including:
- The name of the medication to be administered
- The prescribed dosage
- The times when the medication is to be administered
- The diagnosis or reason the medicine is needed
e.The length of time for which the medication is to be given or for which this order is in effect.
f.Possible side effects, serious reactions that may occur, and recommended emergency response.
2.Signed parental permission is also required, including:
a.The name of the medication to be administered
- The prescribed dosage
- The times when the medication is to be administered
- The diagnosis or reason the medicine is needed
- The length of time for which the medication is to be given or for which this order is in effect.
- Medication must be brought to the school nurse in the properly labeled original box, container or prescription bottle indicating the name of the medication, time to be given and the recommended dose for your child’s age and size. Most pharmacies will make an extra bottle for the school if you ask them.
- It is the responsibility of the student to report to the nurse’s office for the medication at the prescribed time.
If you have any questions, please feel free to contact your child’s school nurse.
Thank you!
(Please complete other side of form and return)
This form is provided for your use if the need arises for medication during this school year
Request to Administer Medication at School
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Student’s Name Grade Teacher/Homeroom
Name of Medication______
Dosage to be given______Time to be given______
Diagnosis or reason the medicine is needed______
Length of time this medication is to be given or this order is in effect: From ______to ______
Date Date
Potential side effects, serious reaction, and recommended emergency response: ______
Students will be permitted to possess and use Asthma Inhalers and / or Epi-Pens in school with permission from their physician, parents, and the school nurse only to permit immediate access to these emergency medications in order to prevent a life-threatening crisis and not for the convenience of daily administration. Students must report to the nurse’s office when routine daily administration is required.
For Asthma Inhalers (Physician to initial the appropriate box)
I have instructed ______in the proper way to use his/her Asthma Inhaler and It is my professional opinion that this student should be allowed to carry and use this medication by him/herself.
It is my professional opinion that ______should not carry his/her Asthma Inhaler. This medication will be kept in the nurse’s office and administered by the nurse.
For Epi-Pen (Physician to initial the appropriate box)
I have instructed ______in the proper way to use his/her Epi-Pen and it is my professional opinion that this student should be allowed to carry and use this medication by him/herself.
It is my professional opinion that ______should not carry his/her Epi-Pen. This medication will be kept in the nurse’s office and administered by the nurse.
To carry and self administer Asthma Inhaler or Epi-Pen medication, the student must demonstrate to the school nurse the capability for proper self-administration and responsible behavior in assuring that medication availability is restricted from other students. The student will notify the school nurse immediately following each use of an Asthma Inhaler or Epi-Pen. The medication will be confiscated and student privileges lost if school policies are abused or ignored.
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Physician’s name (please print)______Physician’s phone number ______