Administration Of Medical Consent Form - Medication Policy

Simsbury Public Schools

Administration of Medicine Consent Form

AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINES BY THE SCHOOL NURSE OR

EMPLOYEE AUTHORIZED TO ADMINISTER MEDICATIONS UNDER THE BOARD OF

EDUCATION POLICY IN THE ABSENCE OF A SCHOOL NURSE

The Connecticut State Law and Regulations requires an authorized prescriber (physician, dentist, optometrist, advanced practice

registered nurse or physician assistant) written order and parent or guardian’s authorization for a nurse or an employee (authorized to

administer medication under the Board of Education policy) to administer medication in school. In compliance with state law, the

Simsbury Board of Education’s Medication policy is summarized on the reverse side of this form. Please review the requirements and

fill in the following information:

Today’s Date: _______________________

Name of Child

: _________________________________________________Date of Birth: ______________________________

Medication Name: _______________________________Generic Medication Name: __________________________

Controlled Drug: ( ) Yes

( ) No

Condition for which medicine is required: _______________________________________________________________

Administer from: __________ to ____________ Time of Administration: ___________ Dosage ___________________

Method: _______________ Relevant Side Effects ________________________ Plan for side effects _______________

Physician/Dentist/ Optometrist /Advanced Practice Registered Nurse / Physician Assistant

Signature___________________________________________Date _________________________________________

Please print name_____________________________________Phone______________________

Can Student Self administer non controlled medication? ( ) Yes ( ) No

Can Student Self carry non controlled medication?

( ) Yes ( ) No

Should medication be administered on field trips?

( ) Yes ( ) No

Known Food or Drug Allergies? ( ) Yes ( ) No If yes please explain ________________________________________

Comments: _________________________________________________________________________________________

Authorization by Parent/Guardian for the administration of the above medication

To School Personnel:

I hereby request that the above medication that has been ordered by an authorized prescriber (Physician, Dentist,

Optometrist, APRN, PA) for my child_________________________________, be administered by the school nurse or employees that

are medication administration trained and allowed to administer medication in the absence of a school nurse by Board of Education.

( ) Yes ( ) No

I agree with the authorized prescriber (above) that my child may:

self-administer non controlled medication

( ) Yes ( ) No

carry non controlled medication

and the medication will remain under the

responsibility of my child.

I understand that I am authorizing permission for the exchange of information between the prescriber and the school nurse necessary to

ensure the safe administration of such medication. I understand that I must supply the school with the prescribed medication in the

original container dispensed and properly labeled by a physician or pharmacist and will provide no more than a 3 month day supply of

said medication. I understand that this medication will be destroyed if it is not picked up within one week following termination of the

order or one week beyond the close of school.

Parent/Guardian: (print) __________________________________________________________________________

Signature: ______________________________________________________

Date: ____________________

S/P/FORMS/MED FORM/Authorization of Medicine Consent form 3 /2011

Administration Of Medical Consent Form - Medication Policy - Simsbury

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