Authorization For The Possession And Use Of Asthma Inhalers printable pdf download

Vinton County Local School District

Form 5330F3

AUTHORIZATION FOR THE POSSESSION AND USE OF ASTHMA INHALERS

Student Name______________________________________________________Date_____________________________

Address____________________________________________________________________________________________

Authorization is hereby given for the student named above to:

_____received the prescribed medication indicated from the designated school personnel.

_____keep emergency medication in his/her possession

_____self-administer the prescribed medication as permitted by law.

Medication Name____________________________________________________________________________________

Dosage____________________________________________________________________________________________

Date the administration is to begin______________________________________________________________________

Date the administration is to cease______________________________________________________________________

Adverse reactions that should be reported to the physician____________________________________________________

_________________________________________________________________________________________________

Adverse reactions for unauthorized user__________________________________________________________________

_________________________________________________________________________________________________

Procedure to follow in the event that medication does not produce the expected relief from student’s

asthma attack______________________________________________________________________________________

_________________________________________________________________________________________________

Other special instructions_____________________________________________________________________________

__________________________________________________________________________________________________

************************************************************************************************************

Prescriber and parent/guardian names, signatures, and emergency phone numbers are required.

Physician’s Name____________________________________________________Phone__________________________

Physician’s Signature_________________________________________________Date___________________________

Parent/Guardian Name________________________________________________Phone (Home)____________________

Phone (Work_____________________

Other ___________________________

Parent/Guardian Signature_____________________________________________Date_____________________________

Copies must be provided to the building principal and the

school nurse if one is assiged to the student's building.

Authorization For The Possession And Use Of Asthma Inhalers