Letter Of Intent To Provide Medication And Or Nursing Service Task printable pdf download

Letter Of Intent To Provide Medication And Or Nursing Service Task

Shelton

700 S. 1

Street

School

Shelton, WA 98584

District

(360) 426-1687 Fax 427-8610

Letter of Intent to Provide Medication and/or Nursing Service Task(s)

I, _________________________________________, voluntarily, willingly, and without

coercion, agree to provide the following nursing delegated service task(s) for:

(name of student)

_______________Medication Administration

_______________State name/dose of medication, time, and frequency to be given

_______________Nursing Service Procedure

Describe service procedure, including time to be administered, and frequency of

administration__________________________________________________________________

_____________________________________________________________

By signing this Letter of Intent, I acknowledge that I signed this form at the time I was asked,

and agreed, to provide the above service nursing delegated task. I understand that this Letter of

Intent will expire if the conditions of acceptance are substantially changed. I may decide, without

employer penalty, to discontinue providing the service(s) listed above for any reason, including

but not limited to, discomfort with the procedure, inability to conduct the procedure at required

time(s), or fear of potential harm to the student.

I understand that I must be trained in administering the procedure nursing tasks(s) described

above, and agree to participate in such training prior to providing the nursing tasks(s) listed

above, and on an ongoing basis as needed, as determined by the registered nurse or advanced

registered nurse practitioner who is delegating this (these) duty(ies) to me.

________________________________

________________

Signature of Delegate

Date

________________________________

_________________

Signature of RN/ARNP who is delegating

Date

Letter Of Intent To Provide Medication And Or Nursing Service Task