School Medication Administration Authorization Form 2004

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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

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