Authorization For Medication Administration By School Personnel printable pdf download

Authorization for Medication Administration by School Personnel

Complete and Return to School

To Principal of ______________________________________________________________________________________________

School Name

Student Name:__________________________________________ DOB:_________ Grade:________ Teacher:_________________

I am giving school personnel permission to administer medications to my child per the following (Complete all underlined sections):

Medication’s Name:

Check One:

□

)

Prescription Requires physician direction (see below

Dose (prescribed amount, e.g. 5 mg., not 1 pill)

□

Non prescription

Tablets requiring cutting should be cut by the parent before being

brought to school. Liquid medication requires dosage spoons,

ALL MEDICATION MUST BE IN ITS

available from your pharmacist, to be supplied by parent.

NEWEST ORIGINAL CONTAINER WITH

Route: (circle one):

ACCURATE LABEL.

By:

Mouth

Ear Eye

Nose

Skin

Inhalation

Time of day to be given at school (e.g. 11 a.m., not mid day)

PRESCRIPTIONS MUST BE WRITTEN BY

OREGON-LICENSED PHYSICIANS.

Duration: Start date_____________ end date____________

Reason for Medication:

Special Instructions:

□

Other (Describe)

Please allow my child to self-administer this medication.

Refer to district policy on self-medication). Requires self-

medication agreement form to be signed by parent, school

administrator, and if prescription, consent of physician

(See below)

I understand: I am responsible to provide this medication and maintain the supply as needed; to notify the school in writing of any changes in the

medication or prescriber; to pick up all unused medication by the last day of school (or it will be discarded); this authorization is valid no longer

than one year from this date and applies only to the medication above; this authorizes an information exchange, as necessary, between the school

nurse, appropriate school personnel, and/or my child’s health provider.

Parent/Guardian Signature:____________________________________________________________ Date:___________________

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

OREGON LICENSED PHYSICIAN DIRECTION

(Required in writing or on pharmacy label for all prescription medications per OAR 581-021-0037

I have prescribed the above medication for the student whose name appears at the top of this form. Instructions in the box are accurate.

Please allow this student to carry and self-administer this medication. (Must be allowed by school district policy. Student must be

developmentally and behaviorally able to self-administer.)

Special instructions including adverse reactions and action required:__________________________________________________

_____________________________________________________________________________________________________________

_______________________________________________

___________________________________________________________

Oregon-Licensed

Physician’s Name (please print/stamp)

Address

___________________________________________________________

_______________________________________________

__________________________ ________________________________

Oregon-Licensed

Physician’s Signature

Phone #

Effective Date

MRX / Med Authorization 01/10 rev.

G / HSS / Forms / MRX

Authorization For Medication Administration By School Personnel

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