Medication Dispensing Form Pennsylvania printable pdf download

September 2013

Dear Parent/Guardian:

In an effort to protect our students, the Central Bucks School District has a medication policy that requires both

parent and physician authorization. Medication will be administered to students during school hours only when such

medication is needed by the student to remain in school and administration is required during school hours. Your

child should not come to school on narcotic medication for pain management as these medications may cause

dizziness, light-headedness and sedation which make it difficult for your child to function safely and effectively in

school.

All medication, both prescription and non-prescription must be kept in the school health office. Medication will be

administered to student during school hours only when such medication is required and accompanied by a doctor’s

order. School nurses are not permitted to dispense medication without a written order from a physician.

With written parent permission, the Central Bucks School District Medical Director’s orders allow for acetaminophen

and ibuprofen administration according to the manufacturer’s suggested dosage. Any deviation from the

manufacturer’s recommended dosage of acetaminophen and ibuprofen require a medication dispensing form.

Administration of certain non-prescription medications is available to all students. These medications include cough

drops, Neosporin ointment and antacid tablets. Administration of all other prescription and non-prescription

medications require completion of the medication dispensing form. The term “medication” includes prescription

drugs as well as non-prescription medication, e.g. cortisone cream, cough medicine, etc.. Completion of the

medication dispensing form requires signatures of both the parent/guardian and the physician. A separate form must

be completed for each medication and be specific as to dosage.

Any medication to be administered by the certified school nurse or staff nurse must be delivered directly to the

school nurse. Medication in baggies, aluminum foil, envelopes, old pill bottles or other family members’ bottles is not

acceptable and will not be administered.

In cases where the Medication Dispensing Form is not available and the administration of the medication is necessary

nurses may obtain verbal orders from the prescribing physician. However any order for this medication to be given at

school on the following day or future days must be accompanied by a completed Medication Dispensing Form signed

by the parent/guardian and physician. In accordance with Act 187 of the School Code and CBSD procedures, students

requiring rescue inhalers and Epi-Pens may be permitted to carry and self-administer medications with a signed

physician’s order, parental permission and competency assessment by the school nurse.Contact your school nurse

with any questions or concerns.

Your cooperation in this matter is appreciated. Our concern is the health and well being of your children. Thank you.

Sincerely,

David Weitzel, Ed.D.

Superintendent

Central Bucks Administration Offices  20 Welden Drive  Doylestown, PA 18901-2359

267-893-2000  Fax: 267-893-5800

Medication Dispensing Form Pennsylvania