HAMILTON COUNTY EDUCATIONAL SERVICE CENTER

ADMINISTRATION OF MEDICATION AT SCHOOL

School policy requires consent of the parent/legal guardian and a written statement (order) from the licensed prescriber before medication can be given to a student by school personnel. The following information is necessary in order to comply with this policy. ALL REQUESTED lNFORMATION MUST BE COMPLETED IN FULL. Please return the completed form to the school office.

STUDENT DOB GRADE___HOMEROOM________

ADDRESS

TELEPHONE ________________________

TO BE COMPLETED BY THE STUDENT'S LICENSED PRESCRlBER

The above mentioned student is under my care for (diagnosis): ________________________________

and should receive_______________________________ _____________________________

Name of Drug Dosage and Route

at the following times____________________________________________________________

Specific instructions for administration: _____________________________________________

Possible side effects: ___________________________________________________________

Effective date: ________________________ Expiration date of this request: _________________

___________________________________________________________________________

Licensed Prescriber Signature Date Phone#

MEDlCATION MUST COME TO SCHOOL IN THE ORlGlNAL CONTAINER WITH THE AFFIXED LABEL FROM THE PHARMACIST. THE LABEL MUST SHOW THE STUDENT'S NAME, THE NAME OF THE MEDICATION, THE DOSAGE DIRECTIONS, THE LICENSED PRESCRIBER'S NAME AND THE RX NUMBER (IF THERE IS ONE).

TO BE COMPLETED BY THE PARENT/GUARDIAN

I give my permission for the principal or his/her designee to administer the medication as prescribed above to my child and further agree to the following:

1. Submit to school personnel a revised statement signed by the licensed prescriber of the above medication when any change in the original statement (order) occurs.

2. Submit to school personnel a written statement when medication, given on a daily or as needed basis, has been discontinued.

3. Grant permission for the school nurse to confer with the above licensed prescriber regarding my child's health and treatment issues as they pertain to the above medication/diagnosis and his/her educational and behavioral management needs.

4. Cooperate with school personnel in assisting my child to comply with medication administration

Instructions.

5. Provide safe transportation of the medication to and from school.

______________________________________ _________________

Parent/Guardian Signature Date

THlS PERMlSSlON FORM IS NO LONGER VALlD AFTER THE END OF THE CURRENT SCHOOL YEAR

HCESC 8/98