507.2E1 Authorization for Administration of Medication

Code No. 507.2E1

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION

Section 1: Parent/Guardian completes

Student:______________________________________      Date of Birth:______________________________

School:_______________________________________        Grade:___________________________________

Parent/Guardian:_______________________________        Phone:___________________________________

Section 2: Physician completes for prescription medication. Asthma/airway constricting, Epipen, or over-the counter medications are the only medications allowed for self-carry/self-administer. Parent/Guardian completes for over-the-counter medications (7-12 grades only and student must complete Section 3).

I hereby authorize and request you to administer to the above named student:

MEDICATION        DOSAGE    TIME        DURATION    SELF-CARRY/SELF-ADMINISTER

1.______________________________________________________________        ▢ YES      ▢ NO

2.______________________________________________________________        ▢ YES        ▢ NO

3.______________________________________________________________        ▢ YES        ▢ NO

Additional instructions:__________________________________________________________________________

Diagnosis/medical reason for medication:___________________________________________________________

Allergies:____________________________________________________________________________________

Physician: When ordering this medication self-carry/self-administer, I understand that the student will carry this medication at school.  I also understand this student will be entirely responsible for the use of this medication and will not be monitored by school personnel.

Parent: Medication will be administered at school or school activities according to the prescription instructions with a record kept by the school. This information is confidential except as provided under the Family Education Rights and Privacy Act (FERPA). I agree to coordinate and work with school personnel and prescriber when concerns arise, to ensure safe delivery of medication to and from school, and to make arrangements for remaining medication at the end of the school year.

Pursuant to Iowa Code §280.16, the school district or accredited nonpublic school and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication by the student.  The signature of the parent/guardian on this form is an acknowledgement of the same.

Pursuant to Iowa Code §148, §150, or §150A, a person licensed under these chapters (physician, physician’s assistant, advanced registered nurse practitioner, or other person licensed or registered to distribute or dispense a prescription drug or device) in the course of professional practice in Iowa in accordance with Iowa Code §147.107, or a person licensed by another state which, under Iowa law, may legally prescribe drugs, provides written authorization containing the student’s name, medication name, dosage, and administration instructions.

____________________________________________________________________________________________    
Physician/Parent/Guardian Signature            Print name                    Date

____________________________________________________________________________________________
Physician/Parent/Guardian phone                Physician fax

▢ Parent/Guardian: If the medication will be SELF-CARRY/SELF-ADMINISTER (asthma/airway constricting or Epipen) this requires a physician’s signature in Section 2, or (over-the-counter) your signature in Section 2, and student signature in Section 3.

1. I/we hereby authorize my student to self-carry and self-administer the above named medication(s) during school hours.  I/we have read the student agreement and have reviewed this with my student (see Section 3).
2. I/we understand my student will carry this medication at school.  I/we also understand my student is entirely responsible for the use of this medication and use of this medication will not be monitored by school personnel.
3. I have reviewed the Self-Carry and Self-Administration agreement with my student.  I/we have taken responsibility for my student understanding this agreement.  My student has signed the agreement in Section 3.

Section 3: SELF-CARRY and SELF-ADMINISTRATION OF MEDICATION - STUDENT AGREEMENT

▢ Inhaler    ⃞ Epipen    ⃞ Over-The-Counter (OTC)    ⃞ Other: _______________________________

I agree to:

    ⃞ Follow my prescribing health provider’s medication orders.
    ⃞ Use correct medication administration technique (correct time, correct route, correct dose).
    ⃞ Not allow anyone else to use my medication.
    ⃞ Keep my medication with me in school and on field trips.
    ⃞ Notify the school nurse or school personnel if the following occurs:

1. My symptoms continue to get worse after taking the medication.
2. I suspect that I am having side effects from my medication.
3. If I have any symptoms of an allergic reaction.
4. If my medication is lost or stolen while at school or a school related activity.

_________________________________________________________________________________________________
Student Signature                            Date

▢ Section 4: PARENT/GUARDIAN AUTHORIZATION FOR ADMINISTRATION BY STAFF

I request that the aforementioned medications, or those checked below, be given to my student during school hours.

1. I will immediately notify the school of any change in the medication or physician’s order, dosage change, frequency, or duration of administration.
2. I give permission for the School Nurse to consult with this student’s physician concerning any questions that arise with regard to the listed medication, medical condition, or side effects of this medication.
3. The school intends to use the requested information to provide for your child’s health and safety needs while at school.  You may refuse to supply the requested personal information/consent to exchange information and this will not impact administration of medication to your child per the physician’s order.  This may result in an incomplete health and safety plan for your child.  The information you provide will only be shared with staff in the school whose jobs require access to this information to ensure your child’s safety and school success.
4. For administration of prescription and/or over-the-counter medications:
   
   1. Parent has provided a signed and dated authorization/electronic authorization to administer medication or provide health service.
   2. Medication is in original, labeled container as dispensed or manufacturer’s labeled container and will be stored in the nurse’s office.
   3. Student requests the medication as needed.
   4. Authorization is renewed annually and when the parent notifies the school that changes are necessary.
   5. Any unused medication left at the end of the school year will be properly disposed of (in accordance with 79 Fed. Reg. 53520, 53546) if prior arrangements are not made by the parent:                                         ▢ I will pick up  or   ▢ Please dispose

Over the counter medications that can be administered to students by authorized school personnel on an as needed basis and with parental permission:

⃞    Tylenol (acetaminophen)            Topical:
⃞         Ibuprofen                               ⃞ Anti-itch/anti-inflammatory (i.e. hydrocortisone, Calagel,
⃞    Cough drops                                   Benadryl cream, etc.)                    
⃞     Antacids (TUMs)                        ⃞ Antibiotic ointment (i.e. Bacitracin, Neosporin)
⃞    Benadryl

_________________________________________________________________________________________________
Parent/Guardian signature                        Date

Approved  10/11/17

Revised 2/6/22

Grinnell-Newburg School District, Grinnell, IA