Looking for a Authorization Form Templates? Download it for free!

Regional School District No. 16

Beacon Falls/ Prospect Connecticut

Authorization for Medication Administration by School Personnel

Connecticut State Law requires a written order from an authorized prescriber (MD, DDS, OD, DO, PA, APRN (or for interscholastic

and intramural athletic events only – podiatrist). and parent/legal guardian/eligible student (18 years old or emancipated minor)

authorization for both prescription and non-prescription medications. All medications shall be delivered to the school by the parent,

guardian, eligible student or other responsible adult. The medication must be stored in the original labeled container as dispensed from

the pharmacy or in the unopened over the counter packaging. No more than a three month supply of medication may be left at school.

Name of Student:______________________________

DOB:

Grade: ______________

Trade Name of Medication: _____________________Generic Name of Medication: ____________________

Dosage: __________________ Route of Medication: _____________________________________________

Frequency/Time in School: _________________________________________________________________

Reason for Medication: _____________________________________________________________________

Possible Side Effects and Management: _______________________________________________________

________________________________________________________________________________________

Known Allergies:__________________________________________________________________________

Dates to be Administered: From: __________ To: ___________

Is this a controlled drug?

Yes

If not a controlled drug, this student is capable and authorized to self-administer this medication: Yes

“yes”,

prescriber training is required:

Student has been trained in self-administration of this medication in prescriber’s office:

Yes

I do

I do not wish that the medication be administered on field trips and shortened days.

Special Instructions: _______________________________________________________________________

Signature:

(Physician/Authorized Prescriber)

Address:

Phone:

Date: _________________

∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗

Parent/Legal Guardian or Eligible Student Authorization

I hereby give my permission for qualified school personnel to administer to my child the medication ordered above by his or

her authorized prescriber (MD, DDS, OD, DO, PA, APRN (or for interscholastic and intramural athletic events only- DP).

Any misuse of this medication will result in disciplinary consequences following the Regional School District No. 16 Board

of Education policy and procedure. I understand that this medication will be destroyed if it is not picked up within one week

following termination of the order or by the last day of school whichever comes first.

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 may be authorized by the authorized prescriber and parent/legal guardian/eligible

student and approved by the school nurse in accordance with Regional School District No. 16 Board of Education

policy/procedure.

School Nurse approval for self-administration: { Yes

{ No

______________________________________

RN Signature: _____________________________ Date: _______________________________________

Authorization For Medication Administration By School Personnel Form - Regional School District No.16

Related Articles

Related forms

Related Categories