Administration of Medication Prescribed medications must arrive in a container with the original, unaltered prescription label attached. The label must display all legal information required for a pharmacist to dispense a prescription medication such as valid issue and expiration dates, the patient s name, the medication name and dosage instructions, and the doctor s name. The label information must match the physician's order. Over-the-counter medications must arrive in the original, unopened store-issued container. The container must be labeled with the child s full name and birth date and the date the parent sends the medication to school. The Medication/Treatment Authorization Form must be completed entirely and accompany any medication (either prescribed or over-the-counter) to be given to a student in school. Both a parent/legal guardian and the prescribing doctor must sign the form for prescription medication. Staff will not be able to assist in the provision or self-administration of medication to your child without this written consent. The Medication/Treatment Authorization Form solely applies to consent for the assistance of the provision or selfadministration of prescription or over-the-counter medications to students. Administration of certain medications by staff to students requires delegation by a licensed nurse pursuant to Montana law. Assistance with the provision or self-administration of medication is limited to the following acts: Verbal suggestions, prompting, reminding, gesturing, or providing a written guide for self-administering medications; Opening the lid of the above-referenced container for the student; Guiding the hand of the student to self-administer the medication; Holding and assisting the student in drinking fluid to assist in the swallowing of oral medications; Assisting with removal of a medication from a container for students with a physical disability which prevents independence in the act. The Authorization for Possession or Self-Administration of Asthma, Severe Allergy, or Anaphylaxis Medication must be completed entirely by the parents and the physician for a student to be allowed to possess and/or selfadminister asthma, severe allergy or anaphylaxis medication. The parent, legal guardian, or an authorized adult must hand carry medications to the school. District personnel, upon receipt, will verify the quantity of each medication. Parents may not send medications to school with your child. The parent or legal guardian will need to pick up the medication at the end of the school year or if the medication is discontinued or changed during the school year. If the medication is not picked up, it will be discarded.
MEDICATION/TREATMENT AUTHORIZATION FORM Student s Name Sex Date of Birth Grade School Name The following section is to be completed by the parent or legal guardian: I hereby grant permission to the principal or his/her designee of School to assist in the selfadministration of the prescribed or over-the-counter medication and/or treatment to my child while in school and away from school while participating in official school activities. It is my responsibility to notify the school if and when these orders change. Parent/Guardian name: Relationship: Emergency Phone #: Home Phone #: Business Phone #: Address: Signature: Date: Over the Counter Medication Authorized: Instructions to Assist with the Self-Administration by the Student of the Medication: List child s allergies: The following section is to be completed by the prescribing physician for prescription medication: (A separate form must be completed for each medication or treatment prescribed) The student named in this document is under my medical supervision for the diagnosis described below. I have prescribed the following medication/treatment, which is necessary to be given in school. I am aware that trained non-medical staff may administer this physician prescribed service. This order is to be effective for the school year: 20-20 or earlier stop date: Diagnosis (for this medication/treatment): Treatment: Name of Medication: Brand: Generic: Strength(i.e. mg/tab):
Instructions to Assist in the Self-Administration of the Medication by the Student: Amount (i.e.# of tablets or teaspoons): Time(s): Frequency (i.e: q 6 hrs prn): Duration (i.e: 10 days): Route: Oral Topical Subcutaneous I.M. Inhaled Other (describe): Time medication is given at home (if applicable): Possible side effects: Is student authorized to carry and use asthma inhalation medication or Epi-Pen? (The Authorization for Possession or Self-Administration of Asthma, Severe Allergy, or Anaphylaxis Medication must be completed entirely by the parents and the physician for a student to be allowed to possess and/or selfadminister asthma or severe allergy medication or an Epi-Pen.) Has student been instructed in the use of asthma inhaler or EpiPen? Yes / No Other Information: Physician Signature: Date: Physician Name: Office Address: Phone: Fax:
AUTHORIZATION FOR POSSESSION OR SELF-ADMINISTRATION OF ASTHMA, SEVERE ALLERGY OR ANAPHYLAXIS MEDICATION For this student to possess or self-administer asthma, severe allergy, or anaphylaxis medication while in school, while at a school sponsored activity, while under the supervision of school personnel, before or after normal school activities (such as while in before-school or after-school care on school-operated property), or while in transit to or from school or school-sponsored activities, this form must be fully completed by: 1) the prescribing physician/ physician assistant/advanced practice registered nurse, and 2) an authorizing parent, an individual who has executed a caretaker relative educational or medical authorization affidavit, or legal guardian. Student s Name: School: Sex: (Please circle) Female/Male Birth Date: / / City/Town: School Year: (Must be renewed annually) PHYSICIAN S AUTHORIZATION: The above named student has my authorization to carry and self administer the following medication: Medication: (1) Dosage: (1) (2) (2) Reason for prescription(s): Medication(s) to be used under the following conditions (times or special circumstances): I confirm that this student has been instructed in the proper use of this medication and is able to self-administer this medication without school personnel supervision. I have formulated and provided to the parent/guardian or caretaker relative a written treatment plan for managing asthma, severe allergies, or anaphylaxis episodes and for medication use by this student during school hours and school activities. Signature of Physician/PA/APRN Date Phone Number Page 1 of 2
AUTHORIZATION BY PARENT: (may also be completed by an individual who has executed a caretaker relative educational or medical authorization affidavit, or Guardian) As the parent, individual who has executed a caretaker relative educational or medical authorization affidavit, or guardian of the above named student, I confirm that this student has been instructed by his/her health care provider on the proper use of this/these medication(s). He/she has demonstrated to me that he/she understands the proper use of this medication. He/she is physically, mentally, and behaviorally capable to assume this responsibility. He/she has my permission to self-medicate as listed above, if needed. If he/she has used epinephrine during school hours, he/she understands the need to alert the school nurse or other adult at the school who will provide follow-up care, including making a 9-1-1 emergency call. I acknowledge that the school district or nonpublic school and its employees and agents are not liable as a result of any injury arising from the self-administration of medication by the student, and I indemnify and hold them harmless for such injury, unless the claim is based on an act or omission that is the result of gross negligence, willful and wanton conduct, or an intentional tort. I agree to work with the school in establishing a plan for use and storage of backup medication. This will include a predetermined location to keep backup medication to which my child has access in the event of an asthma, severe allergy, or anaphylaxis emergency. I have provided the following backup medication: I understand that in the event the medication dosage is altered, a new self-administration form must be completed, or the health care provider may rewrite the order on his/her prescription pad, and I, the parent/caretaker relative/guardian, will sign the new form and assure the new order is attached. I understand it is my responsibility to pick up any unused medication at the end of the school year, and the medication that is not picked up will be disposed of. I authorize the school administration to release this information to appropriate school personnel and classroom teachers. Parent/Guardian name: Relationship: Emergency Phone #: Home Phone #: Address: Parent/Guardian Signature: Date: