Form 400-23 - Medication Authorization Form
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1
2Exhibit 1 Reg. No. 400-23
FREDERICK COUNTY PUBLIC SCHOOLS/FREDERICK COUNTY HEALTH DEPARTMENT
MEDICATION AUTHORIZATION FORM
This order is valid only for the current school year_____________________ (Including Summer Session)
OR
Start Date: ____/____/_____ to Stop Date: _____/____/____
A new medication administration form must be completed at the beginning of each school year, for each medication and each time there
is a change in dosage, or time of administration of a medication.
•This medication form must be completed fully in order for staff to administer required medication.
•Carefully review the reverse side of this form before completion.
Name:
Date of Birth:
Grade:
HEALTH CARE PROVIDER AUTHORIZATION
Allergies:
Condition for which medication is being administered:
Type:
Dose:
Route:
Oral
_______mg
Name of
2 puffs
Inhalation
Medication:__________________________________
_______
Other_____________
Time of Administration:
If PRN, frequency:
Additional Instructions:
Specific Instructions for Inhaler:
Administer inhaler for symptoms such as: coughing, audible wheezing, complaint of tightness in chest, complaint of shortness
of breath, or other _______________________________________________________________________________.
Is student competent to self-carry medication?
Is student competent to self-administer medication?
Yes
No
Yes
No
Health Care Provider Stamp
Possible Medication Side Effects:
_________________________________________
None expected
Specify:
The Pediatric Center of Frederick, LLC
Health Care Provider’s Name/Title:
(Please Print)
Telephone:
(301) 662-0133
Fax:
(301) 695-8604
Address:
1475 Taney Avenue, Ste 201 Frederick, MD 21702
Health Care Provider’s Signature:
Date:
PARENT/GUARDIAN AUTHORIZATION
I request designated personnel to administer the medication as prescribed by the health care provider above. I certify that I have legal
authority to consent to the administration of medication at school and understand that the health care provider will be contacted if
questions arise regarding the student’s medication order.
nd
Primary Contact Phone:
2
Phone:
Parent/Guardian Signature:
Date:
REGISTERED NURSE REVIEW / AUTHORIZATION
Is student competent to self-carry medication?
Is student competent to self-administer medication?
Yes
No
Yes
No
RN Signature:
Date:
6.13.12
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