Parent Guardian And Authorized Health Care Provider Request For Medication Form (Page 2 of 2) in pdf

IUSD HEALTH SERVICES

949-936-7920

FAX 949-936-7929

PARENT NOTIFICATION FOR THE ADMINISTRATION OF MEDICATION AT SCHOOL

Name of student: __________________________

Dear Parent/Guardian:

Medical treatment is the responsibility of the parent/guardian and an authorized health care provider. An

authorized health care provider is an individual who is licensed by the State of California to prescribe

medication. Both prescription and over the counter medication may be given at school when it is

deemed absolutely necessary by the authorized health care provider that the medications be given during

school hours. The parent/guardian is urged, with the help of your child’s authorized health care

provider, to work out a schedule of giving medication at home whenever possible.

California Education Code, Section 49423 allows school personnel to assist in carrying out an authorized

health care provider's written orders. Designated non-medical school personnel may be assisting with

your child’s medication. They will be trained and supervised by credentialed school nurses. Medication

will be safely stored and locked or refrigerated, if required.

Emergency medicine such as EpiPens or inhalers may be carried by the student when

recommended by an authorized health care provider and parent. When appropriate, the school nurse

will evaluate the student’s ability to safely self-administer the medication based on written district

guidelines (Title 5). Back-up medication should be kept at school for emergency use. Students who have

a serious medical condition (diabetes, epilepsy, etc.) should have an emergency supply of their

prescription medication at school with the appropriate consent forms in the event of a disaster.

If medication is to be administered at school, all of the following conditions must be met:

1. A written statement signed by the licensed authorized health care provider/dentist specifying the

reason for the medication, the name, dosage, time, route and specific instructions for emergency

treatment must be on file at school.

2. A signed request from the parent/guardian must be on file at school.

3. Medication must be delivered to the school by the parent/guardian or other responsible adult.

4. Medication must be in your child’s original, labeled pharmacy container written in English.

5. All liquid medication must be accompanied by an appropriate measuring device.

6. Any tablets requiring partial doses (1/2 or 1/4) must be sent to school already cut.

7. A separate form is required for each medication.

Note: Please discuss your authorized health care provider’s instructions with your child, so that he/she is

aware of the time medication is due at school.

Whenever there is a change in medication, dose, time, or route, the parent/guardian and

authorized health care provider must complete a new form.

THIS REQUEST IS VALID FOR THE CURRENT SCHOOL YEAR

Revised 07-29-09

Parent Guardian And Authorized Health Care Provider Request For Medication Form Page 2