Form 21b - Authorization To Carry/self Administer Asthma Inhaler printable pdf download

NORTH PENN SCHOOL DISTRICT

21B

AUTHORIZATION TO CARRY/SELF ADMINISTER ASTHMA INHALER

(Student to carry copy of this document at all times. Original to be on file in School Nurse’s Office)

FOR PHYSICIAN, CERTIFIED REGISTERED NURSE PRACTITIONER, PHYSICAN’S ASSISTANT USE ONLY

PHYSICIAN, CERTIFIED REGISTERED NURSE PRACTITIONER, PHYSICAN’S ASSISTANT AUTHORIZATION

Student ___________________________________________________ DOB _________________ Grade _____________________

Medication and dose __________________________________________________________________________________________

Time of or circumstances requiring self-administration _______________________________________________________________

Diagnosis ___________________________________________________________________________________________________

Possible side effects/conditions to observe ________________________________________________________________________

____________________________________________________________________________________________________________

IN MY OPINION, THIS STUDENT SHOWS THE CAPABILITY TO CARRY AND SELF-ADMINISTER THE ABOVE-

NAMED MEDICATION.

(It is preferable that additional prescription labeled medication be kept in the School Nurse’s Office in case the first is left at home or

lost.)

Duration of authorization (maximum one (1) school year) _____________________________________________________________

Physician’s signature _________________________________________________ Date ___________________________________

Printed physician’s name ______________________________________________ Phone __________________________________

Address ____________________________________________________________________________________________________

Certified Registered Nurse Practitioner’s signature ________________________________________ Date _____________________

Printed Certified Registered Nurse Practitioner’s name _____________________________________ Phone ___________________

Address ____________________________________________________________________________________________________

Physician’s Assistant signature ___________________________________________ Date _________________________________

Printed Physician’s Assistant name ________________________________________ Phone ________________________________

Address ____________________________________________________________________________________________________

FOR STUDENT USE

I have been instructed in the proper use of my prescribed medication and fully understand how and when to use it. I will use this

medication only according to the above instructions. I will not share this medication under any circumstances. I understand that,

should another student use my medication, or if I misuse the medication, the privilege of carrying my medication with me may be

taken away. I will immediately report lost or missing medication. I also agree to come directly to the school nurse, a teacher, a coach,

or an athletic trainer after using my medication in order to report its use.

Student’s signature ____________________________________________________ Date __________________________________

FOR PARENT/GUARDIAN USE

I request that my child (named above) be permitted to carry/self-administer the above medication as per the order above. I understand

that the medication must be in a properly labeled pharmacy container and properly labeled inhaler. I understand that I, the

parent/guardian, accept the legal responsibility should the above medication be misused, lost, given to, or taken by a person other than

the above-named student, and that, as a result, the privilege of carrying the medication may be taken away. I understand that the

North Penn School District has no legal responsibility to ensure that the medication is taken or when the above-named student

administers his or her own medication and bears no responsibility for the benefits or consequences of the administration of the

medication.

Parent/Guardian signature _________________________________________________ Date ________________________________

Form 21b - Authorization To Carry/self Administer Asthma Inhaler