Allergies/anaphylaxis Medication Administration Form (Page 2 of 2) in pdf

ALLERGIES/ANAPHYLAXIS MEDICATION ADMINISTRATION FORM

Provider Medication Order Form—Office of School Health —School Year 2017–2018

The Following Section to Be Completed by the Student’s Parent/Guardian

I hereby consent to the storage and administration of medication, as well as the storage and use of necessary equipment to administer the medication,

in accordance with the instructions of my child's health care practitioner. I understand that I must provide the school with the medication and equipment

necessary to administer medication, including non-Ventolin inhalers. Medication is to be provided in a properly labeled original container from the

pharmacy (another such container should be obtained by me for my child's use outside of school); the label on the prescription medication must include

the name of the student, name and telephone number of the pharmacy, licensed prescriber's name, date and number of refills, name of medication,

dosage, frequency of administration, route of administration and/or other directions; over the counter medications and drug samples must be in the

manufacturer's original container, with the student's name affixed to that container. I understand that all provided medication must be supplied in

its original and UNOPENED medication box. I further understand that I must immediately advise the school nurse) of any change in the prescription

or instructions stated above.

I understand that no student will be allowed to carry or self-administer controlled substances.

I understand that this consent is only valid until the end of a New York City Department of Education (“DOE”) sponsored summer instruction program

session; or such time that I deliver to the school nurse a new prescription or instructions issued by my child's health care practitioner (whichever is

earlier). By submitting this MAF, I am requesting that my child be provided specific health services by DOE and the New York City Department of Health

and Mental Hygiene (DOHMH) through the Office of School Health (OSH). I understand that these services may include a clinical assessment and a

physical examination by an OSH health care practitioner. Full and complete instructions regarding the above-requested health service(s) are included in

this MAF. I understand that OSH and their agents, and employees involved in the provision of the above-requested health service(s) are relying on the

accuracy of the information provided in this form.

I recognize that this form is not an agreement by OSH and DOE to provide the services requested, but rather my request and consent for such services.

If it is determined that these services are necessary, a Student Accommodation Plan may also be necessary and will be completed by the school.

I understand that OSH and DOE and their employees and agents may contact, consult with and obtain any further information they may deem

appropriate relating to my child's medical condition, medication and/or treatment, from any health care practitioner and/or pharmacist that has provided

medical or health services to my child.

SELF-ADMINISTRATION OF MEDICATION:

Initial this paragraph for use of an epinephrine, asthma inhaler and other approved self-administered medications:

I hereby certify that my child has been fully instructed and is capable of self-administration of the prescribed medication. I further consent

to my child's carrying, storage and self-administration of the above-prescribed medication in school. I acknowledge that I am responsible

for providing my child with such medication in containers labeled as described above, for any and all monitoring of my child's use of such

medication, and for any and all consequences of my child's use of such medication in school. I understand that the school nurse will

confirm my child’s ability to self-carry and self-administer in a responsible manner. In addition, I agree to provide “back up” medication in

______

a clearly labeled container to be kept in the medical room in the event my child does not have sufficient medication to self-administer.

INITIAL

I consent to the school nurse or trained school personnel storing and/or administering to my child such medication in the event that my

______

child is temporarily incapable of self-storage and self-administration of such medication.

INITIAL

SIGN

If you opt to use stocked, you must send your child’s epinephrine, asthma inhaler and other approved

HERE

self-administered medications with your child on a school trip day and/or after-school programs in order

that he/she has it available. The stock epinephrine is only for use while your child is in the school building.

Student Last Name

First Name

School

Date of birth __ __ / __ __ / __ __ __ __

Print Parent/Guardian’s Name

Parent/Guardian's Signature

Date Signed

Parent/Guardian’s Address

__ __ / __ __ / __ __ __ __

Telephone Numbers:

Daytime

Home

Cell Phone

( __ __ __ ) __ __ __ - __ __ __ __

Parent/Guardian E-mail Address:

Alternate Emergency Contact’s Name:

Contact Telephone Number

( __ __ __ ) __ __ __ - __ __ __ __

DO NOT WRITE BELOW – FOR OSH USE ONLY

Received by: Name

Date

Reviewed by: Name

Date

__ __ / __ __ / __ __ __ __

Self-Administers/Self-Carries:

Services provided by:  Nurse  OSH Public Health Advisor  School Based Health Center  DOE School Staff

 Yes  No

Signature and Title (RN OR MD/DO/NP):

*Confidential information should not be sent by e-mail.

Allergies/anaphylaxis Medication Administration Form Page 2

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