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Medication Form - AL State Department of Education 2/16/2016

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ALABAMA STATE DEPARTMENT OF EDUCATION

SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION

School Year:________________________

STUDENT INFORMATION

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:                                                                                                                                       __________________________________________

SPECIAL INSTRUCTIONS:

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: ___________________

 

PARENT AUTHORIZATION

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: (     ) _______-_______

 

SELF-ADMINISTRATION AUTHORIZATION

(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: (     ) _______-______