Regional School District No. 16 - Mdi Self-Administration Authorization Form

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Regional School District No. 16
Beacon Falls/Prospect Connecticut
MDI Self-Administration Authorization
Beacon Falls/Prospect Connecticut
Connecticut State Law requires a written order from an authorized prescriber (MD, DDS, OD, DO, PA, APRN) and
parent/legal guardian/eligible student (18 years old or emancipated minor) authorization for both prescription and non-
prescription medications. The medication must be stored in the original labeled container as dispensed from the
pharmacy. Please instruct the pharmacist to label the inhaler itself, as well as the packaging.
Authorized Prescriber Authorization
Name of Student:
DOB:
Grade: ______________
Trade Name of Medication: __________________________ Generic Name: ___________________________
Dosage:______________ Route of Medication:___________ Frequency/Time in School: _________________
Possible Side Effects and Management:__________________________________________________________
Dates to be Administered: From: __________________ To: ___________________
Known Allergies:
Reason for Medication: ______________________________
Special Instructions: _________________________________________________________________________
Prescriber’s authorization for self-administration: { Yes { No (If “yes”, prescriber training is required.)
Student has been trained in self-administration of this medication in prescriber’s office:
Yes
No
Signature:
(Physician/Authorized Prescriber)
Address:
Phone:
Date: __________________
Parent/Legal Guardian or Eligible Student Authorization
I hereby give permission for my child to carry and self administer the medication ordered above by his or her authorized
prescriber. I understand that this medication will be in my child’s possession during the school day and my child will be
responsible for using it appropriately per the doctor’s orders and under the direction of the school nurse. Any misuse of
this medication will result in disciplinary consequences following Regional School District No. 16 Board of Education
policy and procedure.
I give permission for the release and exchange of information between the school nurse and authorized prescriber
necessary to ensure the safe administration of such medication.
Signature of Parent/Legal Guardian/Eligible Student: _____________________________________ Date: ____________
__________________________________________
Home Phone: ___________________________ Cell Phone:
***************************************************************************************************************************************
School Nurse Authorization
Self-administration of medication is authorized by the authorized prescriber and parent/legal guardian/eligible student and
approved by the school nurse in accordance with Regional School Board No.16 policy/procedure.
School Nurse approval for self-administration: { Yes
{ No
_____________________________________________
RN Signature: ____________________________________
Date:
__________________________________________

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