Medication Authorization For Cms Students Form/authorization For Self-Medication By Cms Students Form

AUTHORIZATION FOR SELF-MEDICATION BY CMS STUDENTS

Student's Name__________________________________________ Birthdate______________________

Medication___________________________________for ____________________________________

Eligibility: In accordance with CMS Policy JLCD, Administering Medications to Students, and its

accompanying regulation, JLCD-R, only students who meet the following descriptions may possess and

self-administer medications: (1) Students with special medical needs such as asthma and/or severe

allergies or who are subject to anaphylactic reactions and may require emergency medications (i.e.,

asthma inhaler or epinephrine auto-injector [“Epi-pen]); and (2) Students who require frequent

administrations of non-prescription medications or prescription medications that are not controlled

substances.

Healthcare Provider: The student named above has (1) asthma or an allergy that could result in an

anaphylactic reaction and may require emergency medications; or (2) a condition that requires frequent

administration of a prescription or non-prescription medication. The medication is not a controlled

substance. This student is capable of, has been instructed on the procedures for and has demonstrated the

skill to self-administer this medication as directed on page 1 of this form. Please allow him/her to self-

administer the medication during school hours and as otherwise indicated on page 1 of this form.

This student will not require adult supervision while taking this medication.

Physician signature/date_________________________________________

Parent/Guardian: I give consent to the Charlotte-Mecklenburg Schools to allow my child to self-

administer this medicine at school. I understand that my child and I assume responsibility for the proper

use and safekeeping of this medicine. If the medication that is prescribed for my child is for the treatment

of asthma or anaphylactic reactions, I agree to provide a supplementary supply of the medication that will

be kept by the school in a location to which my child has immediate access. I absolve the Charlotte-

Mecklenburg Board of Education and their agents and employees from any and all liability whatsoever

that may result from my child possessing or taking this medicine at school. I further consent for the

information about my child included on pages 1 and 2 of this form to be shared with appropriate school

staff as necessary for the safety of my child.

Parent signature/date _____________________________________

Student: I am capable of taking this medicine as recommended and accept this responsibility. I will

keep it secure at all times and will not share it with others. I understand that I will be subject to discipline

under the Student Code of Conduct if I abuse the privilege of being allowed to self-medicate while at

school or school sponsored activities. Unless the medication is prescribed for the treatment of asthma or

anaphylactic reactions, I understand that I will lose the privilege of self-administering my medication if I

do not follow these rules.

Student signature/date ____________________________________

School Nurse: I have reviewed this request and acknowledge that this student has demonstrated the skill

level to self-administer this medication. I have informed this student that he or she must tell an

appropriate staff member whenever he or she has used the medication at school.

Nurse signature/date __________________________________________________

Rev 8/06 lp

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Medication Authorization For Cms Students Form/authorization For Self-Medication By Cms Students Form - 2006 Page 2