- The person(s) designated to administer medication receives a written request, signed by the parent(s) having care of charge of the student, that the drug be administered to the student.
- The person(s) designated to administer medication receives a statement, signed by the physician or other person licensed to prescribe medication, which includes all of the following information:
The parent(s)/guardian(s) agree to submit a revised statement signed by the physician who prescribed the drug to the person designated to administer medication if any of the information provided above changes.The person(s) authorized to administer the drug receives a copy of the statement described above.The drug is received by the person(s) authorized to administer the drug in the container in which it was dispensed by the prescribing physician. All drugs shall be stored in an established location in a locked storage. Drugs which require refrigeration may be kept in a refrigerator in a place not commonly used by students.
- the name, birthdate, and address of the student;
- school and class in which the student is enrolled;
- parent's signature and telephone numbers;
- name of the drug and the dosage to be administered;
- times or intervals at which the dosage of the drug is to be administered;
- date on which the administration of the drug is to begin;
- date on which the administration of the drug is to cease;
- any severe adverse reaction which should be reported to the physician and one or more telephone numbers at which the person who prescribed the medication can be reached in case of an emergency and;
- special instruction for administration of the drug, including sterile condition and storage.
All medicine forms are available below. Click to view or print the forms.