Medication Administration Record General Medication Form printable pdf download

Medication Administration Record (MAR)

General Medication Form

(Including Asthma Inhaler and Epinephrine Autoinjector Use)

Student Information

Student name

Date of birth

Student address

School

Grade/Class

Teacher

School year

List any known drug allergies/reactions

Height

Weight

Prescriber Authorization

Name of medication

Circumstance for use

Dosage

Route

Time/Interval

Date to begin medication

Date to end medication

Circumstances for use

Special instructions

Treatment in the event of an adverse reaction

Epinephrine Autoinjector

❏ Not applicable

❏ Yes, as the prescriber I have determined that this student is capable of possessing and using this autoinjector appropriately and have provided the student

with training in the proper use of the autoinjector.

Asthma Inhaler

❏ Not applicable

❏ Yes, if conditions are satisfied per ORC 3317.716, the student may possess and use the inhaler at school or at any activity event or program sponsored by or in which the

student's school is a participant.

Procedures for school employees if the student is unable to administer the medication or if it does not produce the expected relief

Possible Severe Adverse Reaction(s) per ORC 3317.716 and 3313.718

a) To the student for whom it is prescribed (that should be reported to the prescriber)

b) To a student for whom it is not prescribed who receives a dose

Other medication instructions

Does medication require refrigeration? ❏ Yes ❏ No Is the medication a controlled substance? ❏ Yes ❏ No

Prescriber signature

Date

Phone

Fax

Prescriber name (print)

Reminder note for prescriber: ORC 3313.718 requires backup epinephrine autoinjector and best practice recommends backup asthma inhaler.

Parent/Guardian Authorization

I authorize an employee of the school board to administer the above medication. þ I understand that additional parent/prescriber signed statements will be necessary if the

dosage of medication is changed. þ I also authorize the licensed healthcare professional to talk with the prescriber or pharmacist to clarify medication order.

Medication form must be received by the principal, his/her designee, and/or the school nurse. þ I understand that the medication must be in the original container and be properly

labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration and the date of drug expiration

when appropriate.

Parent/Guardian signature

Date

#1 contact phone

#2 contact phone

Parent/Guardian Self-Carry Authorization

For Epinephrine Autoinjector: As the parent/guardian of this student, I authorize my child to possess and use an epinephrine autoinjector, as prescribed, at the school and any activity, event, or

program sponsored by or in which the student’ s school is a participant. I understand that a school employee will immediately request assistance from an emergency medical service provider if this

medication is administered. I will provide a backup dose of the medication to the school principal or nurse as required by law.

For Asthma Inhaler: As the parent/guardian of this student, I authorize my child to possess and use an asthma inhaler as prescribed, at the school and any activity, event, or program sponsored by

or in which the student’ s school is a participant.

Parent/Guardian signature

Date

#1 contact phone

#2 contact phone

HEA 7758 5/11

❏

File per district policy