Mcps Form 525-14 Release And Indemnification Agreement Agreement For Epinephrine Auto Injector - Maryland, Montgomery County Public Schools Page 2
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1
2INFORMATION/PROCEDURES
1.
The authorized prescriber prescribed Epinephrine Auto Injector WILL NOT BE
ADMINISTERED IN SCHOOL OR DURING SCHOOL sponsored activities without
a parent/guardian signed authorization and waiver and an authorized prescriber’s
order/authorization for students with a known diagnosis of anaphylaxis.
2.
This form must be on file in the student’s health folder. The parent/guardian is
responsible for obtaining the authorized prescriber’s order/authorization. (See Part II.)
The principal or school nurse will ensure that all items on the form are complete.
3.
The parent/guardian is responsible for submitting a new form to the school each
school year and whenever there is a change in dosage or a change in conditions
under which the epinephrine auto injector is given.
4.
An authorized prescriber may use office stationery/prescription pad in lieu of
completing Part II. Information necessary includes: student’s name, allergen for
which the epinephrine auto injector is being prescribed, brand name, amount of
pre-measured epinephrine, order for repeat dose if deemed necessary, authorized
prescriber’s signature and date.
5.
Medication must be properly labeled by a pharmacist and must match the authorized
prescriber’s order. If the authorized prescriber’s orders include a repeat epinephrine
auto injector, an additional epinephrine auto injector must be provided by the
parent/guardian.
6.
Medication must be hand-delivered to the school by the parent/guardian or, under
special circumstances, an adult designated by the parent/guardian. Under no
circumstances will either the school nurse or school (MCPS) personnel administer
medication brought to school by the student.
7.
All medication kept in the school will be stored in a secure area accessible only to
authorized personnel.
8.
Any unused medication will be collected by the parent/guardian within one week
after the end of the school year.
9.
In no case may the school nurse or school staff member administer epinephrine to a
student who is identified as subject to anaphylactic reaction outside the framework of
the procedures outlined above.
10. An authorized prescriber’s order and parent/guardian permission are necessary
for self-carry/self-administered emergency medications such as epinephrine auto
injector for anaphylaxis. The school nurse must evaluate and approve the student’s
ability and capability to self-administer medication. It is imperative that the student
understands the necessity for reporting to either the health staff or MCPS staff
following self administration of an epinephrine auto injector, so 911 may be called.
11. The school nurse will call the prescriber, as allowed by HIPAA, if a question arises
about the student and/or the student’s medication.
12. Use MCPS Form 525-13, Authorization to Administer Prescribed Medication, Release
and Indemnification Agreement, for all other prescribed medications.
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