Scheduled And "As Needed" (Prn) Medication Permission Form
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2Scheduled and As-Needed “PRN” Medication Permission
SCHEDULED AND “AS NEEDED” (PRN) MEDICATION PERMISSION
Only necessary medication (prescribed for, but not limited to the treatment of: ADD/ADHD, Asthma, Diabetes, and
Epilepsy) may be given at school. All medication should be given outside of school hours, if possible. Three-times-a-
day medications should be given before school, after school and at bedtime for optimal coverage. Should school
personnel refuse to give medication, the parent/guardian is informed and the incident documented. If necessary,
medication can be given at school only under the following conditions:
1.
If medication is needed in order for a student to remain in school, this form must be completed by the
parent/guardian, signed by the physician, and returned with the medication to the nurse or principal designee.
2.
All necessary medication prescribed for a student must be signed by a physician, dentist, physician assistance,
podiatrist, or nurse practitioner and parent/guardian. All prescription medication must be in the prescription bottle
and labeled with a current pharmacy prescription label. “Over-the-counter” medication must be in its original
labeled container and have the student’s name on the bottle.
Medications sent in baggies or unlabeled
containers will not be given. “Over-the-counter” include cough drops, ointments, and eye drops and may not be
given without a physician and parent signature.
3.
It is the responsibility of the parent/guardian to bring all medication to the clinic/office and to pick up unused
medicine. Any medicine unused that is not picked up will be destroyed.
4.
Experimental medication/dosages will not be given.
Herbal medication, dietary supplements, and other
nutritional aids not approved as medication by the FDA will not be administered at school.
5.
Only antibiotics prescribed to be taken four times a day with noon, as one of those times will be dispensed.
6.
Medications must be kept in locked cabinet/drawer in the school office/clinic and administered in the school
office/clinic. Unless other considerations are made.
7.
A student may need medication in a school-related event. The principal is to authorize a school employee to
administer medication. The medication must be in the original container, a photocopy of the parental permit, and
the time(s) the medication is to be given.
8.
Only the school nurse can give nebulizer treatments in school.
Non-licensed school personnel are not
permitted to administer this treatment. The parent must came to school to give the treatment if there is no nurse.
9.
No one-time medication such as an antibiotic or sedative will be given.
10. Complete the “As-Needed Medications, Special Medication or Treatment” section for medications that are “prn”
any other route other than oral and for special treatments needed.
11. Special forms must be filled out for emergency medications such as those for allergies. A special form must be
filled out when a student is to carry asthma medication.
SCHOOL:
NAME OF STUDENT:
ROOM:
GRADE:
NAME OF MEDICATION
and STRENGTH
DOSAGE:
TIME(S)
ROUTE
DIRECTIONS FOR GIVING
BEGINNING DATE:
ENDING DATE:
AS-NEEDED MEDICATION, SPECIAL MEDICATION OR TREATMENT SECTION
A.
Circumstances warranting requested PRN treatment/medication:
1.
Condition requiring treatment/medication
:
Signs and symptoms of condition:
2.
Signs and symptoms that require
3.
medication and/or treatment to be
given.
4.
Length of time signs and symptoms present to warrant treatment/medication
:
July 2008
78
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