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Jefferson County Public Schools (JCPS)

2012-2013

Authorization to Give Over the Counter Medication

(This Form Requires a Healthcare Provider’s Signature)

Dear Parent/Guardian:

This form is regarding over the counter medications given during the school day. All medication should be given at

home when possible. However, if given at school, the medication will most likely be administered by trained, unlicensed

JCPS personnel. In order for school personnel to administer any type of medication to your child, we must have this

signed and notarized authorization form on file. Also, for over the counter medication to be given a healthcare

provider’s signature is required. As a reminder, the first dose of any new medication should not be given at school.

Also, before sending any medication(s) to school, please read and follow the directions below.

 All information below must be completed and notarized before returning it to school.

 A separate Authorization to Give Over the Counter Medication Form must be completed for each medication

to be given at school.

 The medication must be sent to school in the original labeled container.

 Medications should be brought to school by parent/guardian and will be counted with a trained JCPS staff

member. If you cannot personally bring the medication to school, it must be sent in a sealed envelope with the

student’s name written on the outside. A follow-up call should be made to the school office staff to inform them

your child is bringing their medication and to confirm the number of pills. School staff should have another JCPS

school staff member witness the phone call and the number of pills will be noted on the Medication

Administration Records (MAR). If the envelope is open, NO medication should be given and the parent must

come to the school and confirm medication and number of pills. If medication is sent to school in an envelope, the

parent accepts all responsibility while medication is in transit from home to school.

 At the end of the school year, you will be requested to pick up any unused medication. If medication is not

picked up as requested, medication will be appropriately disposed of by school staff and/or district nurses and a

witness.

 Medication may be given 30 minutes before to 30 minutes after the time medication ordered.

 If a medication is stopped prior to the “date to stop medication” indicated on this form, you must send a note to

the school informing them.

 This form(s) expire(s) at the end of the school year; however, when there are changes to the medication, times, or

dosages you will be required to complete a new Authorization to Give Over the Counter Medication Form.

Sincerely,

Principal

Authorization To Give Over The Counter Medication Form - Jefferson County Public Schools - 2012-2013