Medication Administration Authorization Form 2006 Page 2
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2MEDICATION PROCEDURE INFORMATION
Mount de Sales Academy requirements for medication administration must be followed in order for students
to take medication during school hours and school sponsored events.
1. Parents must provide a written authorization for any medicine to be administered. This includes over-the-counter
medicine (including medicated cough drops), homeopathic medicine, and prescription medicine. A separate order
form is required for each medication to be administered.
2. The first dose of any new prescription must be given at home.
3. The parent/guardian is responsible for obtaining a written medication order. The attached medication order form is
preferred. The authorized health care provider must sign the order form. Necessary information includes:
- name of student
- route of administration
- allergies
- date of medication order
- date order expires
- special instructions
- name of medication
- authorized health care provider
- time and frequency of medication
signature
- dosage and strength of med.
- diagnosis (reason for administration
- possible side effects
of medication, specify all)
Note: PRN medications should have the frequency of repeat doses clearly indicated.
4.
Occasionally students may need to self-administer/carry medication such as an inhaler or emergency medication. A
written medication order, signed by an authorized health care provider and consented to by parent / guardian, that
specifically states that the student may self administer/carry medication, must be on file in the health room for any
student who self-administers/carries medication throughout the school day. The student must report to the school
nurse any self administration.
5.
A new medication order is required for each new school year.
6.
The medication should be delivered to the school by the parent/guardian or, under special circumstances, an adult
designated by the parent. Students should not transport medication to or from school.
7.
All medication must be properly labeled and consistent with the medication order. Pharmacy containers and labeling
are preferred; a second labeled container can be obtained by asking the pharmacist, Physician samples must be
appropriately labeled by the physician or parent/guardian.
The following information must be on the Pharmacy label:
- Name of student
- name of medication
- dosage and strength of medication
- Date of medication order
- route, time and frequency of medication
- authorized health care provider name
-special instructions
8.
Parents must label over-the-counter medications with the student’s name.
9.
The school nurse must approve the medication order before the first dose of medication can be administered at
school.
10.
The parent is responsible for submitting a new medication order form to the school each time there is a change of
dose, time of administration, or route of administration. The parent must provide the medication for as long as it is
prescribed.
11.
All medication kept in the school will be stored in a locked area accessible only to authorized personnel.
12.
Within one week after the expiration of the medication order, the parent/guardian/adult designee must personally
collect any unused portion of the medication. Medication not claimed within the period will be destroyed.
13.
Expired medication cannot be given. The effective expiration date of a medication is the earlier of either the
pharmacy labeled expiration date or the manufacturer expiration date.
14.
Each student's confidentiality will be maintained to the extent possible by school staff. At times, school personnel
outside of the health room may need to be made aware by health room staff that a student is receiving medication in
order to monitor effectiveness, side effects, adverse reactions, or in response to other legitimate school related issues
or responsibilities. Information will be shared on a need to know basis only.
15.
Under no circumstances may any school staff administer any medication outside the procedures outlined in the
Maryland State Department of Education Medication Administration Procedure.
16.
Mount de Sales High School Inc. does not assume responsibility for medication administered outside the Maryland
State Department of Education Medication Administration Procedure.
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