Asthma Inhaler - Kenston Local Schools printable pdf download

Asthma Inhaler - Kenston Local Schools

Form 5330 F3a

Ohio Department of Health

Authorization for Student Possession and

Use of an Asthma Inhaler

In accordance with ORC 3313.716/3313.14

A completed form must be provided to the school principal and/or nurse before the student may possess and use an

asthma inhaler in school to alleviate asthmatic symptoms, or before exercise to prevent the onset of asthmatic symptoms.

Student name

Student address

This section must be completed and signed by the student’s parent or guardian.

As the Parent/Guardian of this student, I authorize my child to possess and use an asthma inhaler, as prescribed, at the school and

any activity, event, or program sponsored by or in which the student’s school is a participant.

Parent /guardian signature

Date

Parent/Guardian name

Parent/Guardian emergency telephone number

(

)

This section must be completed and signed by the student’s physician.

Name and dosage of medication

Date medication administration begins

Date medication administration ends (if known)

Procedures for school employees if the medication does not produce the expected relief

Possible severe adverse reactions:

To the student for which it is prescribed (that should be reported to the physician)

To a student for which it is not prescribed who receives a dose

Special instructions

Physician signature

Date

Physician name

Physician emergency telephone number

(

)

Adapted from the Ohio Association of School Nurses

HEA 4223 3/07

Asthma Inhaler - Kenston Local Schools