Worcester County Public Schools
School Medication Administration Authorization Form
This order is valid only for the current school year _________, including the summer session.
School: ________________________________________________________________________________________________________________
This form must be completed fully in order for schools to administer the required medication. A new medication administration form must be
completed at the beginning of each school year, for each medication, and each time there is a change in dosage or time of administration of a
medication.
•
Prescription medication must be in a container labeled by the pharmacist or prescriber.
•
Non-prescription must be in the original container with the label intact.
•
An adult must bring the medication to the school.
•
The school nurse (RN) will call the prescriber, as allowed by HIPPA, if a question arises about the child and/or the child’s medication.
Prescriber’s Authorization
Name of Student: __________________________________________________
Date of Birth: _____________
Grade: __________
Condition for which medication is being administered: ___________________________________________________________________________
Medication Name: _________________________________________
Dose: _____________________
Route: __________________
Time/frequency of administration: ____________________________________________________
If PRN, frequency: ________________
If PRN, for what symptoms: ________________________________________________________________________________________________
Relevant side effects:
None expected
Specify: ____________________________________________________________________________
Medication shall be administered from: __________________ to __________________
MM/DD/YY
MM/DD/YY
Prescriber’s Name/Title: ___________________________________________________
(type or print)
Telephone: ________________________
Fax: ____________________________
Address: ________________________________________________________________
_______________________________________________________________
Prescriber’s Signature: _____________________________________ Date: __________
(Original signature or signature stamp only)
(Use for Prescriber’s Address Stamp)
A verbal order was taken by the school RN: ____________________________________________ for the above medication on ________________.
Name
Date
PARENT/GUARDIAN AUTHORIZATION
I/We request designated school personnel to administer the mediation as prescribed by the above prescriber. I/We certify that I/we have legal
authority to consent to medical treatment for the student named above, including the administration of medication at school. I/We understand that at
the end of the school year, an adult must pick up the medication, otherwise it will be discarded. I/We authorize the school nurse to communicate
with the health care provider as allowed by HIPAA.
Parent/Guardian Signature: __________________________________________________________
Date: ___________________________
Home Phone #: ______________________________
Cell Phone #: __________________________
Work Phone #: _____________________
SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL
Self carry/self administration of emergency medication may be authorized by the prescriber and must be approved by the school nurse according to
the State medication policy.
Prescriber’s authorization for self carry/self administration of emergency medication: ___________________________________________________
Signature
Date
School RN approval for self carry/self administration of emergency medication: _______________________________________________________
Signature
Date
Order reviewed by the school RN: ____________________________________________________________________________________________
Signature
Date
MD State 2004