Form 1/2012 Sgk - Authorization For The Administration Of Medicine By School Personnel
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1School District: __________________________
School: ____________________________ Grade: _________
AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINE BY SCHOOL PERSONNEL
Connecticut State Law and Regulations 10-212(a) require a written medication order of an authorized prescriber, (physician, dentist,
optometrist, advanced practice registered nurse or physician assistant and, for interscholastic and intramural athletic events only, a podiatrist)
and parent/guardian written authorization, for the nurse, or in the absence of the nurse, a designated principal or teacher to administer
medication. Medications must be in the original properly labeled container and dispensed by a physician/pharmacist.
Prescriber’s Authorization
Name of Student: ______________________________________________ Date of Birth: _____________________
Address: ______________________________________________________________________________________
Condition for which drug is being administered: ______________________________________________________
Name and Generic name of Drug: ____________________________ Dose: __________________ Route: ________
Time of Administration: __________________________________ If PRN, frequency: ________________________
Relevant side effects:
None expected
Specify: _______________________________________________
ALLERGIES:
NO
YES (specify): ______________________________________________________________
Medication shall be administered from: _______________________________ to ___________________________
(
Month / Day / Year)
(Month / Day / Year)
Prescriber’s Name/Title: ________________________________________________
(Type or print)
Telephone: _____________________________ Fax: _________________________
Address: ____________________________________________________________
Prescriber’s Signature: ________________________________ Date: ____________
School Nurse Signature: _______________________________ Date: ____________
Use for Prescriber’s Stamp
_____________________________________________________________________________________________
PARENT/GUARDIAN AUTHORIZATION
I hereby request that the above ordered medication be administered by school personnel and I give permission for the exchange of
information between the prescriber and the school nurse necessary to ensure the safe administration of this medication. I understand that I
must supply the school with no more than a three (3) month supply of medication. I understand that this medication will be destroyed if not
picked up within one week following termination of the order or the last day of school, whichever comes first.
Parent/Guardian Signature: ______________________________________ Date: ___________________________
Parent’s Home Phone #: _______________________ Cell # _________________ Work # _____________________
_____________________________________________________________________________________________
SELF ADMINISTRATION OF MEDICATION AUTHORIZATION/APPROVAL
Self administration of medication may be authorized by the prescriber and parent/guardian and must be approved by the school nurse in
accordance with Board policy. In the case of inhalers for asthma and cartridge injectors for medically-diagnosed allergies, students may self-
administer medication with only the written authorization of an authorized prescriber and written authorization from a student’s parent or
guardian or eligible student.
Prescriber’s authorization for self administration:
Yes
No ____________________________________
Signature
Date
Parent/Guardian authorization for self administration:
Yes
No ____________________________________
Signature
Date
School nurse approval for self administration:
Yes
No ____________________________________
Signature
Date
Sample Form 1/2012 SGK
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