Medication Administration Authorization Form 2006
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1
2Mount de Sales Academy
MEDICATION ADMINISTRATION AUTHORIZATION FORM*
* a separate form is required for each medication
This order is valid only for school year (current) _______________________________
This form must be completed fully in order for the Mount de Sales school nurse (or medication technicians) 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 medication 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 HIPAA, if a question arises about the child and/or the child’s medication.
Prescriber’s Authorization
Name of Student:
Date of Birth:
Grade: _______ Allergies: __________
Condition(s) for which medication is being administered:
Medication Name:
Strength:
Dose:
Route: __________________ Frequency: __________________________ Time: ____________________ RX Date: _____________
Relevant side effects:
None expected
Specify:
Special Instructions: ___________________________________________________
Medication shall be administered from:
to
Month
Day / Year
Month
Day
Year
I
I
I
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 (Name): __________________ for the above medication on (Date):__________________
PARENT/GUARDIAN AUTHORIZATION
I/We request designated school personnel to administer the medication 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
Parent / Guardian consent 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
MDSA version 3 3/15/06
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