ALABAMA STATE DEPARTMENT OF EDUCATION
SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION
Student’s Name: _______________________________ School: ___________________________________
Date of Birth: _____/_____/______ Age: _________ Grade: ______ Teacher: _____________________
ÿ No known drug allergies---if drug allergies list: ________________________ Weight: ________pounds
PRESCRIBER AUTHORIZATION (To be completed by licensed healthcare provider)
Medication Name: ______________________________ Dosage: ______________Route: ______________
Frequency/Time(s) to be given: ___________________ Start Date: ___/____/____ Stop Date: ___/___/___
Reason for taking medication: __________________________________________
Potential side effects/contraindications/adverse reactions: __________________________________________
Treatment order in the event of an adverse reaction: __________________________________________
Is the medication a controlled substance? Yes ÿ No ÿ
Is self- medication permitted and recommended? Yes ÿ No ÿ
If “yes” I hereby affirm this student has been instructed
On proper self-administration of the prescribe medication.
Do you recommend this medication be kept “on person” by student? Yes ÿ No ÿ
Printed Name of Licensed Healthcare Provider: ____________________Phone: ( ) _______-_______ Fax: _____-______
Signature of Licensed Healthcare Provider: ___________________________________________ Date: ___________________
I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to administer or to delegate to unlicensed school personnel the task of assisting my child in taking the above medication in accordance with the administrative code practice rules. I understand that additional parent/prescriber signed statements will be necessary if the dosage of medication is changed. I also authorize the School Nurse to talk with the prescriber or pharmacist should a question come up with the medication.
Prescription Medication must be registered with School Nurse or trained Medication Assistants. Prescription medication must be properly labeled with student’s name, prescriber’s name, name of medication, dosage, time intervals, route of administration and the date of drug’s expiration when appropriate.
Over the Counter Medication must be registered with the School Nurse or Trained Medication Assistant, OTC’s in the original, unopened and sealed container. Local Education Agency Policy for OTC medication to be followed:
Parent’s/Guardian’s Signature: ___________________________Date: ___/___/___Phone: ( ) _______-_______
(To be completed ONLY if student is authorized to complete self-care by licensed healthcare provider.)
I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the school, the agents of the school, and the local board of education against any claims that may arise relating to my child’s self-administration of prescribed medication(s).
Signature of Parent: ______________________________________ Date: ____/____/______ Phone: ( ) _______-______