Request To Administer Medication At School (Page 2 of 2) in pdf

This form is provided for your use if the need arises for medication during this school year

Request to Administer Medication at School

_________________________________________ __________

___________________________________

Student’s Name

Grade

Teacher/Homeroom

Name of Medication__________________________________________________________________________

Dosage to be given_________________________

Time to be given_______________________________

Diagnosis or reason the medicine is needed________________________________________________________

Length of time this medication is to be given or this order is in effect: From _____________to ______________

Date

Potential side effects, serious reaction, and recommended emergency response: ___________________________

Students will be permitted to possess and use Asthma Inhalers and / or Epi-Pens in school with permission from

their physician, parents, and the school nurse only to permit immediate access to these emergency medications in

order to prevent a life-threatening crisis and not for the convenience of daily administration. Students must report

to the nurse’s office when routine daily administration is required.

For Asthma Inhalers (Physician to initial the appropriate box)

I have instructed __________________________in the proper way to use his/her Asthma Inhaler and It is

my professional opinion that this student should be allowed to carry and use this medication by him/herself.

It is my professional opinion that __________________________should not carry his/her Asthma

Inhaler. This medication will be kept in the nurse’s office and administered by the nurse.

For Epi-Pen (Physician to initial the appropriate box)

I have instructed _________________________ in the proper way to use his/her Epi-Pen and it is my

professional opinion that this student should be allowed to carry and use this medication by him/herself.

It is my professional opinion that ________________________should not carry his/her Epi-Pen. This

medication will be kept in the nurse’s office and administered by the nurse.

To carry and self administer Asthma Inhaler or Epi-Pen medication, the student must demonstrate to the school

nurse the capability for proper self-administration and responsible behavior in assuring that medication

availability is restricted from other students. The student will notify the school nurse immediately following each

use of an Asthma Inhaler or Epi-Pen. The medication will be confiscated and student privileges lost if school

policies are abused or ignored.

___________________________________________________________________________________________

Physician’s name (please print)_______________________ Physician’s phone number _________________

Physician’s Signature________________________________________________Date_____________

Parent/Guardian Signature___________________________________________ Date______________

Request To Administer Medication At School Page 2