CLOVIS MUNICIPAL SCHOOLS GEN 588
SCHOOL MEDICATION ADMINISTRATION AUTHORIZATION FORM
This order is valid only for the school year (current) _____________________ including the summer session.
This form must be completed fully in order for schools to administer the required medication. A new
medication administration form must be completed at the beginning of each school year, for each medication
to be administered, and each time there is a change in dosage or time of administration of a medication.
Prescription medication must be in a container labeled by the pharmacist or prescriber.
Nonprescription medication must be in the original container with the label intact.
An authorized adult must bring the medication to the school.
An authorized adult must pick up the medication at the end of the prescribing period or it will be discarded.
The school nurse will share information relevant to the prescribed medication as he/she determines to be appropriate
for your child’s health and safety. The school nurse will also call the prescriber, as allowed by HIPAA, if a question
arises about the child and/or the child’s medication.
Student Name: ___________________________________ Date of Birth: _______________ Grade: ___________
Condition for which medication is being administered: ________________________________________________
Medication Name: ___________________________________ Dose: _______________ Route: _______________
Time/Frequency of administration: ________________________________ If PRN, frequency: _______________
If PRN, for what symptoms: _____________________________________________________________________
Relevant side effects: None expected Specify: __________________________________________________
Medication shall be administered from: _____________________________ to _____________________________
Prescriber’s Name/Title_____________________________________________ Telephone: __________________
Fax: ______________________ Address: __________________________________________________________
Prescriber’s Signature: ________________________________________________ Date: ____________________
I/We request designated school personnel to administer the medication as prescribed and as instructed by the above prescriber.
I/We certify that I/we have legal authority to consent to medical treatment for the student named above, including the
administration of medication at school. I/We agree to furnish the necessary medication in a pharmacy/original labeled container;
to provide replacement medication as necessary; and to provide a new authorization form if there is ANY change in the
medication, dosage, administration time, administration route, or special instructions regarding the medication. I/We authorize
the school nurse to communicate with the health care provider as allowed by HIPAA.
Parent/Guardian Signature: ______________________________________________ Date: __________________
FOR OFFICE USE:
Medication received by _______________________________________________________________________________
(Signature of School Personnel Receiving the Medication) Date
Action Plan/SelfCarry Forms received: YES NO
Medication and Authorization Reviewed by RN: ___________________________________________________________
CMS REV. 3/2016