Allergies/anaphylaxis Medication Administration Form Page 2


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.
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.
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.
If you opt to use stocked, you must send your child’s epinephrine, asthma inhaler and other approved
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
Date of birth __ __ / __ __ / __ __ __ __
Print Parent/Guardian’s Name
Parent/Guardian's Signature
Date Signed
Parent/Guardian’s Address
__ __ / __ __ / __ __ __ __
Telephone Numbers:
Cell Phone
( __ __ __ ) __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
Parent/Guardian E-mail Address:
Alternate Emergency Contact’s Name:
Contact Telephone Number
( __ __ __ ) __ __ __ - __ __ __ __
Received by: Name
Reviewed by: Name
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
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.


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