Treatment Authorization/order Form
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1Everett Public Schools
Health Services
TREATMENT AUTHORIZATION/ORDER (RCW28A.210.280/370)
This form is for independent, non- independent, and non delegable treatment
This order is for the current school year only
Date: _________________________________________________
Student Number: ___________
Student Name: _________________________________________
DOB: _____________________
School: ________________________________________________
Grade: ____________________
Parent/Guardian: ______________________________________ Home Phone: ___________________
Work Phone: _______________ Cell Phone: _________________ E-Mail: _____________________
Licensed Health Care Provider (LHCP): ___________________________________________________
Clinic Name: _________________________Office Phone: ____________________ FAX: ___________
Medication/treatments should be administered/performed at school only when absolutely necessary. Whenever possible the
parent/guardian and licensed health care provider (LHCP) are urged to design a schedule outside of school hours. It is understood
that trained unlicensed personnel may administer oral medication and perform some treatments per state law, but may not administer
eye/ear drops or topicals (non delegable per nursing licensure). Student must be able to self administer/apply topicals, and eye/ear
drops. All medication will be stored in a secure place. The medication/treatment to be given at school must have a written order
signed by a licensed health care provider and have a parent/guardian signature. Any medication must be in the original, properly
labeled container. This includes any over the counter medication and office samples. The school accepts no responsibility for
adverse reactions when the medication is dispensed in accordance with the licensed health care provider order.
I certify that this student requires the following treatment/medication during school hours
(determined by licensed health care provider authorizing treatment).
Diagnosis: _____________________________________________________________________________
Treatment/Medication and level of self care
:
Catheterization
Independent
Needs Assistance
Time of treatment: _____________________________________________________________________
Colostomy Care
Independent
Needs Assistance
Time of treatment: ____________________________________________________________________
G-Tube Feeding
Independent
Needs Assistance
Feeding Solution: __________________ Amount: ______________________ Time(s): __________
Amount of water to follow feeding: ___________________________________
Medication via tube: _______________________ Dosage: ________________ Time(s): __________
Nebulizer Treatment
Independent
Needs Assistance
Medication: _____________________ Dosage: ___________Time(s) of treatment: ______________
Ear Drops
Independent
Non-delegable
Time of treatment: ___________________________________________________________________
Eye Drops
Independent
Non-delegable
Time of treatment: ___________________________________________________________________
Topicals (ointments/creams/lotions)
Independent
Non-delegable
Time of treatment: ___________________________________________________________________
Other: ________________________
Independent
Needs Assistance
Time of treatment: ___________________________________________________________________
Specific treatment instructions: _______________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Other comments/concerns: ___________________________________________________________
___________________________________________________________________________________
Licensed Health Care Provider Signature: __________________________________ Date: _________________
Parent/Guardian Signature: ______________________________________________ Date: _________________
Student (if independent): ________________________________________________ Date: _________________
District Nurse: _________________________________________________________ Date: _________________
Treatment Order 3/08
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