AUTHORIZATION FOR STUDENTS TO CARRY A PRESCRIPTION INHALER, EPINEPHRINE AUTO INJECTOR, INSULIN, AND DIABETIC SUPPLIES, OR OTHER APPROVED MEDICATION

Transcription

1 AUTHORIZATION FOR STUDENTS TO CARRY A PRESCRIPTION INHALER, EPINEPHRINE AUTO INJECTOR, INSULIN, AND DIABETIC SUPPLIES, OR OTHER APPROVED MEDICATION needs to carry the following prescription labeled inhaler, epinephrine auto injector, insulin, and diabetic supplies, and/or prescription medication with him/her. The above-named student has been instructed in the proper use of the medication and fully understands how to administer this medication. It is preferable that a second prescription inhaler, epinephrine auto injector, additional insulin, and diabetic supplies or other prescribed medication be kept in the school in case the first is lost or left at home. Name of Medication: Physician's Name Physician's Address Physician's Signature I have been instructed in the proper use of my prescription labeled medication and fully understand how it is administered. I will not allow another student to use my medication under any circumstances. I also understand that should another student use my prescription, the privilege of carrying my medication may be altered. I also accept responsibility for notifying the School Nurse each time I take my medication. Student's Signature I hereby request that the above-named student, over whom I have legal guardianship, be allowed to carry and use this prescribed medication at school: I accept legal responsibility should the medication be lost, given to, or taken by another person other than the above-named student. I understand that if this should happen, the privilege of carrying the medication may be altered. I release Forsyth County School System and its employees of any legal responsibility when the abovenamed student administers his/her own medication. Parent/Guardian Signature Updated 6/12

2 REQUEST FOR ADMINISTRATION OF MEDICATION INSULIN If medications can be given at home or after school hours, please do so. However, if medication administration is absolutely necessary to be given during school hours, this form must be completed. Permission is hereby granted to the local school principal or his/her designee to supervise my child in taking the following prescribed medication. I hereby release and discharge the Forsyth County Board of Education and its employees and officials from any and all liability in case of accident or any other mishap in supervising said medication due to any side effects, illness, or other injury which might occur to my child through supervising said medication. I hereby release aforementioned officials from any liability because of any injury or damage which might occur. I give the above-mentioned personnel permission to contact my child s health care provider and/or pharmacy to acquire medical information concerning my child s diagnosis, medication, and other treatment(s) required. I understand that: a. All medications, herbals, and supplement must be approved by the U.S. Food and Drug Administration and appear in the U.S. Pharmacopeia b. Medications must be in the original container. c. Parent/Guardian must provide specific instructions (including drugs and related equipment) to the principal or his/her designee. d. It will be the responsibility of the parent/guardian to inform the school of any changes in pertinent data. New medications will not be given unless a new form is completed. e. All medication will be taken directly to the office by the parent or guardian. Students may not have medication in their possession, except with a physician s request or a physician s order on a Forsyth County care plan. f. Students who violate these rules will be in violation of the Alcohol/Illegal Drug Use Policy (JCDAC). g. A daily record shall be kept on each medication administered. This record will include student s name, date, medication administered, time, and signature of school personnel who supervised. h. MEDICATIONS MUST BE PICKED UP BY PARENT/GUARDIAN. Any medication not picked up from the school by the end of the last school day of the year will be considered abandoned. Abandoned medication will be properly discarded in accordance with local, state, and federal laws/rules by the school nurse and an administrator. NAME OF STUDENT BIRTH SCHOOL Liberty Middle School GRADE MEDICATION OF PRESCRIPTION Amount to give TIME to give medication ALLERGIES STOP MEDICATION ON PHYSICIAN S NAME PHYSICIAN S PHONE PHYSICIAN S FAX STATEMENT OF PARENT OR GUARDIAN I hereby give my permission for my child to receive this medication at school. SIGNATURE OF PARENT/GUARDIAN HOME PHONE WORK PHONE CELL ******************************************************************************************************************************** To be completed by Physician for long-term medications (more than two weeks): Physician as defined in Article 2 of the Medical Practice Act of Georgia CONDITION/ILLNESS REQUIRING MEDICATION POSSIBLE SIDE EFFECTS OF MEDICATION OTHER MEDICATION STUDENT IS TAKING PHYSICIAN S SIGNATURE Liberty Middle School 7465 Wallace Tatum Rd. Cumming, GA Ph x Fax

3 REQUEST FOR ADMINISTRATION OF MEDICATION GLUCAGON If medications can be given at home or after school hours, please do so. However, if medication administration is absolutely necessary to be given during school hours, this form must be completed. Permission is hereby granted to the local school principal or his/her designee to supervise my child in taking the following prescribed medication. I hereby release and discharge the Forsyth County Board of Education and its employees and officials from any and all liability in case of accident or any other mishap in supervising said medication due to any side effects, illness, or other injury which might occur to my child through supervising said medication. I hereby release aforementioned officials from any liability because of any injury or damage which might occur. I give the above-mentioned personnel permission to contact my child s health care provider and/or pharmacy to acquire medical information concerning my child s diagnosis, medication, and other treatment(s) required. I understand that: i. All medications, herbals, and supplement must be approved by the U.S. Food and Drug Administration and appear in the U.S. Pharmacopeia j. Medications must be in the original container. k. Parent/Guardian must provide specific instructions (including drugs and related equipment) to the principal or his/her designee. l. It will be the responsibility of the parent/guardian to inform the school of any changes in pertinent data. New medications will not be given unless a new form is completed. m. All medication will be taken directly to the office by the parent or guardian. Students may not have medication in their possession, except with a physician s request or a physician s order on a Forsyth County care plan. n. Students who violate these rules will be in violation of the Alcohol/Illegal Drug Use Policy (JCDAC). o. A daily record shall be kept on each medication administered. This record will include student s name, date, medication administered, time, and signature of school personnel who supervised. p. MEDICATIONS MUST BE PICKED UP BY PARENT/GUARDIAN. Any medication not picked up from the school by the end of the last school day of the year will be considered abandoned. Abandoned medication will be properly discarded in accordance with local, state, and federal laws/rules by the school nurse and an administrator. NAME OF STUDENT BIRTH SCHOOL Liberty Middle School GRADE MEDICATION OF PRESCRIPTION Amount to give TIME to give medication ALLERGIES STOP MEDICATION ON PHYSICIAN S NAME PHYSICIAN S PHONE PHYSICIAN S FAX STATEMENT OF PARENT OR GUARDIAN I hereby give my permission for my child to receive this medication at school. SIGNATURE OF PARENT/GUARDIAN HOME PHONE WORK PHONE CELL ******************************************************************************************************************************** To be completed by Physician for long-term medications (more than two weeks): Physician as defined in Article 2 of the Medical Practice Act of Georgia CONDITION/ILLNESS REQUIRING MEDICATION POSSIBLE SIDE EFFECTS OF MEDICATION OTHER MEDICATION STUDENT IS TAKING PHYSICIAN S SIGNATURE Liberty Middle School 7465 Wallace Tatum Rd. Cumming, GA Ph x Fax

4 DIABETES EMERGENCY: Seizure or Unconscious Name of Student Grade a. Don t panic b. Has 911 been called? c. Have the parents been called? d. If convulsions, protect head! DO NOT PUT ANYTHING IN MOUTH!!!!! e. Prepare Glucagon (Only persons designated by parents) f. Remove flip-off seal from bottle of glucagon. f. Remove needle protector from syringe, and inject the entire contents of the syringe into the bottle of glucagon. (Do not remove plastic clip from syringe.) f. Remove syringe from bottle f. Swirl bottle gently until glucagon dissolves completely. (GLUCAGON SHOULD NOT BE USED UNLESS THE SOLUTION IS CLEAR AND OF A WATER-LIKE CONSISTENCY.) f. Inject Glucagon (Only persons designated by parents) g. Using the same syringe, hold bottle upside down and gently withdraw the amount prescribed by the physician. (See page 57 Health Care Provider Authorization for School Management of Diabetes) g. Cleanse upper outer thigh with alcohol swab. g. Insert needle into the muscle and completely inject all of the solution. (THERE IS NO DANGER OF OVERDOSE!) g. Apply light pressure at the injection site and withdraw the needle. g. Turn the patient to his/her side. When an unconscious person awakens, he/she may vomit. Turning the patient to his/her side prevents choking. g. HE/SHE SHOULD AWAKEN WITHIN 15 MINUTES OF INJECTING GLUCAGON. If not, he/she could be unconscious due to severe high blood sugar, which requires medical attention immediately! h. Feed the patient as soon as he/she awakens and IS ABLE TO SWALLOW. Foods to give: Other instructions: Parent/Guardian Signature Contact Numbers Physician Signature Printed Physician Name. List of Persons trained to give Glucagon: 1. School Nurse and/or Substitute School Nurse 2. Liberty MS designated staff member in the event that the school nurse is not available. 3. I give permission for the above persons to administer glucagon to my child, who is diabetic, in the even that he/she has a seizure or becomes unconscious. Parent Signature Physician s Signature Printed Physician s Name

5 Clinic Supplies Needed for Diabetes Care 1. Supply of juice and peanut butter or cheese or protein crackers to be left in the clinic 2. Glucagon Pen with prescription label on it, not expired 3. Insulin in the original box with the prescription label on it, not expired 4. Pump supplies if student is using a pump 5. Syringes 6. Blood glucose meter 7. Blood glucose strips for meter, not expired 8. Lancets 9. Glucose gel or chewable tablets 10. Storage bin big enough to keep all the supplies in (shoe box size) 11. Diabetic Action Care Plan signed by your child s doctor. This needs to be filled out and updated, and signed every year 12. Medication Administration Release Form filled out and signed by doctor for insulin, glucagon pen, and medication. This form also needs to be re done every year 13. Ketone sticks to check Ketones if BG is over 300