Form 11970262.1 - Physician'S Request For Administration Of Medication In School Building During School Hours - Dekalb County School District
ADVERTISEMENT
1DEKALB COUNTY SCHOOL DISTRICT
STUDENT HEALTH SERVICES
PHYSICIAN’S REQUEST FOR ADMINISTRATION OF MEDICATION
IN SCHOOL BUILDING DURING SCHOOL HOURS
Must be Completed Annually
1.
To keep this child in optimal health and to help maintain school performance, it is necessary that medication be given
during school hours.
2.
Nurses and other designated school personnel can assist with self-administration of medication during school hours.
3.
In order for medication to be self administered at school, this form must be completed by licensed physician and at least
one guardian/parent and be returned to school.
School:
Name of child:
DOB
Diagnosis:
Infectious
Noninfectious
(Please check one)
Allergies:
Name of medication:
Color, if applicable
(Include trade name)
Route of Administration:
Form of medication to be given (specify below):
tablet
pill
capsule
liquid
inhalation
injection**
other
** No injection will be given except in extreme emergency, such as allergy to wasp or bee sting or the like.
Dosage (amount to be given):
Frequency:
Side Effects:
Physician’s Signature
(date)
Physician’s Name (print or type)
/
Physician’s Office Phone/Fax#
*This is your permission to give medication to my child named above as requested by the physician.
/
Parent’s Signature
(date)
Home Phone#
Work Phone#
/
Pager/Cell#
Email address
*MEDICATION MUST BE DELIVERED TO SCHOOL BY A RESPONSIBLE ADULT IN THE CONTAINER IN
WHICH IT WAS DISPENSED BY THE PRESCRIBING PHYSICIAN, LICENSED PHARMACIST OR
PHARMACY.
Any unused and or expired portions of any medications that are not collected by the parent/guardian within one week
will be destroyed.
Revised 3/22/11
11970262.1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal