Request For Medication/treatment During School Hours Form printable pdf download

STAFFORD COUNTY PUBLIC SCHOOLS HEALTH SERVICES

REGULATIONS ON MEDICATION ADMINISTRATION

REQUEST FOR MEDICATION/TREATMENT DURING SCHOOL

HOURS

Stafford County Public Schools require that if medication/treatments are to be taken by a student while

he/she is in school or participating in school activities, the school MUST have the following information

completed and on file in the health clinic:

A signed order from the health care provider renewed yearly

A signed consent from the parent or guardian

The medication in the original pharmacy container.

THIS APPLIES TO ANY MEDICATION, PRESCRIPTION OR OVER THE COUNTER.

All medication must be kept in the school health office. It is the responsibility of the student to come to

clinic for administration at the proper time. Student possession and self-administration of certain

medications are permitted for conditions such as Diabetes, Asthma, and Allergy. More specific

documentation from health care provider and supporting materials are required. Families should request

an appointment with the school nurse in these cases.

To be completed by the Health Care Provider:

Student: __________________________ Grade: ______ School: _________________________

Medication/Treatment: __________________________________________________________

Dosage, Frequency, Route: ______________________________________________________

Diagnosis: ____________________________________________________________________

Medication/Treatment Required:

School Year

Short Term _____________

Date required

Special Instructions, Side Effects, Comments: _______________________________________

____________________________________________________________________________

HealthCare Provider Signature: ____________________________________________________

Health Care Provider PRINTED Name: _____________________________________________

Address: ______________________________________________________________________

Telephone: ___________________________________Date: _____________________________

To Be Completed By Parent or Guardian:

I request that school personnel administer the above medication/treatment ordered by the health care

provider, according to the directions provided. I authorize a representative of the school to share

information/lab results regarding this medication/treatment with the above health care provider and

school staff as necessary for the students health and safety at school. I understand and agree to comply

with the school’s policies and procedures as stated on the back of this form.

__________ ___________________________________________________

Date

Signature of Parent/Guardian

PLEASE TURN PAGE AND

READ REGULATIONS ON MEDICATION ADMINISTRATION

Revised 11/2013

Chapter 6-F

Request For Medication/treatment During School Hours Form