School Medication Authorization Form printable pdf download

JORDAN SCHOOL DISTRICT NURSING SERVICES

SCHOOL MEDICATION AUTHORIZATION FORM

School Year ____________________

Student’s Name __________________________________

Birthdate ______________________

School ___________________________ Grade _________ Teacher ________________________________

TO BE COMPLETED BY HEALTHCARE PROVIDER:

This order can only be signed by Physician (MD, DO), Dentist, Nurse Practitioner (NP, FNP, PNP, APRN/PP), or Certified

Physician’s Assistant. Utah Law (53a-11-501) requires that medication administered during school hours must be

medically necessary.

ONLY ONE MEDICATION PER FORM

Diagnosis ________________________________________________________________________________________

Medication __________________________________________Duration to be given ____________________________

Dosage __________________________ Time _______________________Route ______________________________

Reportable adverse reactions/side effects _______________________________________________________________

________________________________________________________________________________________________

Special instructions ________________________________________________________________________________

Medication Self-Administration Authorization:

[ ] Yes

[ ] No

The above named student is under my care. I feel it is medically appropriate and the student is trained and capable to

carry and self-administer the following indicated medications at all times:

[ ] Inhaler

[ ] Insulin

[ ] Epi-Pen

Name of healthcare provider ______________________________________________ Phone ____________________

Healthcare provider signature _____________________________________________ Date ______________________

PARENTAL RESPONSIBILITES:

Parent must furnish the school with a completed School Medication Authorization Form prior to any medications

•

being administered by school personnel.

The medication must be delivered by the parent in the original container, labeled with the child’s name,

•

medication, time, dosage, and healthcare provider’s name.

All medication must be delivered to the school by an adult and picked up by an adult within two weeks of last dose

•

given.

If there is a change in the medication or medication dosage, a new School Medication Authorization Form must be

•

completed before school personnel can administer the new medication.

I UNDERSTAND THAT BY SIGNING THIS FORM:

I am giving permission to the school personnel to contact the healthcare provider regarding this medication,

•

I am giving permission for this medication to be administered by someone other than a licensed nurse who has

•

been appointed by the school administrator.

Parent Signature _____________________________ Date ___________ Emergency Phone Number ________________

District Nurses Signature __________________________________

White – School Copy

Yellow – District Nurse Copy

Pink - Parent Copy

5/2007

School Medication Authorization Form

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