School Medication Administration Form 2004
ADVERTISEMENT
1MARYLAND STATE
SCHOOL MEDICATION ADMINISTRATION AUTHORIZATION FORM
This order is valid only for school year (current) ___________________ including the summer session.
School: _________________________________________________________________________________________________
This form must be completed fully in order for schools to administer the required medication. A new medication
administration form must be completed at the beginning of each school year, for each medication, and each time there is a
change in dosage or time of administration of a medication.
* Prescription medication must be in a container labeled by the pharmacist or prescriber.
* Non-prescription medication must be in the original container with the label intact.
* An adult must bring the medication to the school.
* The school nurse (RN) will call the prescriber, as allowed by HIPAA, if a question arises about the child and/or the child’s medication.
Prescriber’s Authorization
Name of Student: ___________________________________ Date of Birth: ___________________________ Grade: __________
Condition for which medication is being administered: ______________________________________________________________
Medication Name: ______________________________________Dose: ______________________Route: ___________________
Time/frequency of administration: ____________________________________________ If PRN, frequency: __________________
If PRN, for what symptoms: __________________________________________________________________________________
□
□
Relevant side effects:
None expected
Specify: ______________________________________________________________
Medication shall be administered from: ________________________________to________________________________
Month I Day / Year
Month I Day I Year
Prescriber’s Name/Title:_______________________________________
(Type or print)
Telephone: _______________________FAX: _____________________
Address:___________________________________________________
___________________________________________________
Prescriber’s Signature: _________________________Date:__________
(Original signature or signature stamp ONLY)
(Use for Prescriber’s Address Stamp)
A verbal order was taken by the school RN (Name): _______________________ for the above medication on (Date): ___________
PARENT/GUARDIAN AUTHORIZATION
I/We request designated school personnel to administer the medication as prescribed by the above prescriber. I/We certify that I/we
have legal authority to consent to medical treatment for the student named above, including the administration of medication at
school. I/We understand that at the end of the school year, an adult must pick up the medication, otherwise it will be discarded.
I/We authorize the school nurse to communicate with the health care provider as allowed by HIPAA.
Parent/Guardian Signature: _______________________________________________________ Date: ______________________
Home Phone #: _____________________ Cell Phone #: _______________________ Work Phone #: _______________________
SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL
Self carry/self administration of emergency medication may be authorized by the prescriber and must be approved by the school
nurse according to the State medication policy.
Prescriber’s authorization for self carry/self administration of emergency medication: _____________________________________
Signature
Date
School RN approval for self carry/self administration of emergency medication: __________________________________________
Signature
Date
Order reviewed by the school RN: _____________________________________________________________________________
Signature
Date
2004
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Education