Medication Administration Record General Medication Form (Page 2 of 2) in pdf

Medication Drop-Off and Pick-up Instructions

for Parent/Guardian

School Year

Date

Dear parent of __________________________________________,

Student Name

If your child must take medication during the school year, he/she must have the following:

Part 1: Drop-off and Pick-up Instructions for Parents

Medication drop off instructions

Parent/guardian must drop off medication (or designate a responsible adult) to deliver the medication to school designated location.

The Ohio Revised Code and school district policy state you must have:

❏ Written medication authorization record from your child’s licensed health care prescriber and signed permission from the parent/guardian

(school will provide necessary forms).

❏ Pharmacy-labeled original bottle or original container with student name and grade if non-prescription.

Other Comments

Medication pick up instructions

If your child’s medication is discontinued during or after the end of the school year, safe arrangements must be made for the safe return. Please

indicate your choice of how you prefer us to handle the return of your child’s medication once discontinued by the health care prescriber or at the

end of the school year.

I will come into the school office/clinic when my child’s medication is discontinued by the health care prescriber or it is the end of the school

year.

I request that the school dispose of any medication remaining after the last day of school. (If this form is not returned, medication will be

properly discarded ______ week(s) after school ends.)

I give the school permission to send my child’s:

Epinephrine autoinjector or

Asthma inhaler home with my child on this date _________________________. I assume all responsibility for the medication after it

leaves the school.

Parent/Guardian signature

Date

#1 Contact phone

#2 Contact phone

Part 2: For School Nurse/Personnel Only

Your child, ______________________________has ________ of __________________ left in the clinic.

(amount left)

(medication name)

Please follow all medication instructions above to ensure safe medication practice.

School nurse/School personnel signature

Title

Phone

Date

Please contact the school for any questions or concerns

HEA 7777 5/11

❏

File per district policy

Medication Administration Record General Medication Form Page 2