Medication At School printable pdf download

NS MT-1

CLOVIS UNIFIED SCHOOL DISTRICT

Rev. 5/15

MEDICATION AT SCHOOL

Student's Name

Sex: M / F

Birthdate

Dear Parent/Guardian/Physician:

California Education Code, Section 49423 defines certain requirements for administration of medication "... any pupil who is required to take, during

the regular school day, medication prescribed for him/her by a physician, may be assisted by the school nurse or other designated school

personnel if the school district receives (1) a written statement from such physician detailing the method, amount, and time schedules by which

medication is to be taken, and (2) a written statement from the parent or guardian of the pupil indicating the desire that the school district assist

the pupil in the matter set forth in the physician's statement." CUSD Board Policy No. 2401 does not allow students to administer their own

medication without written permission as stated above.

Additionally, CUSD Administrative Regulation No. 2401 indicates that school personnel are prohibited from administering any over-the-counter or

prescription medications including aspirins, vitamins, antihistamines, etc. unless the medication is accompanied with written permission from both the

parent/guardian and physician. The medication must be clearly labeled and sent to school in a container from the pharmacy and will be kept in the

school office unless otherwise directed by the physician.

At the beginning of each school year or upon entry into school, a "MEDICATION AT SCHOOL" form must be completely renewed.

If you require any additional information regarding the above, please contact me at

(phone)

(fax)

School Nurse

Date

PARENT/GUARDIAN REQUEST

We, the undersigned, who are the parents/guardian of

request that

the school nurse or designated school personnel assist our child in the matter set forth by the physician's statement. In the event of an

untoward or subsequent reaction, it is understood that the school personnel will in no way be held responsible for carrying out this

request.

Signature of Parent/Guardian

Date

FOR STUDENTS WITH ALLERGIES OR EPIPENS : REVERSE SIDE OF THIS FORM

MUST BE COMPLETED BY PHYSICIAN

Medication is needed for the following reason(s):

NAME OF MEDICATION

DOSAGE

TIME(S) TO BE GIVEN

Time limit on medication (i.e., 10 days, 1 month, current school year):

PE instructions:

Self-pace: Yes / No

(circle one)

Inhaler Instructions:

Student may / may not (circle one) carry inhaler.

Student has / has not (circle one) demonstrated to provider appropriate use of inhaler/spacer.

NOTE- To Physician of EPIPEN student: My signature below indicates I am in agreement with the Action

Plan as written on the backside of this form.

************************************************************************************************************

Physician's Name (please print or type)

Physician's Signature

Date ______________________

Address:

Phone

Medication At School

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