NinevehHensleyJacksonUnitedSchoolCorporation

IndianCreekSchools
___________________________________________________________________
REQUESTFORMEDICATIONDURINGTHESCHOOLDAY
Completeoneformforeachprescribedoroverthecountermedication.
Policy/Procedureonreverseside.
StudentName__________________________
DateofBirth__________
ParentorGuardian
________________________________________________________
HomePhone___________________

MUSTBECOMPLETEDBYPHYSICIAN
Nameofmedication/treatment
______________________________________________
Reasonformedication/treatment:
_____________________________________________________

Dose/Schedule:
_____________________________________________________________________

Possibleadversereactions/sideeffects:
________________________________________

ForPRNAsthmainhalersorEpiPensonlycompleteifapplicable:

NOYESThischildhasbeenprovidedadequateinstructionandisbothcapable
ofandresponsibleforselfadministeringthismedication.

NOYESDuetotheseverenatureofthischildsmedicalcondition,Irecommend
thatthischildbeallowedtohavethismedicationinhis/herpossessionandtouseitas
needed.

PhysiciansName______________________________Fax_________________

PhysicianSignature_____________________________Phone_______________

Date______________________
Authorizationvalidforoneschoolyearandmustberenewedannually.

I,theparentorlegalguardianoftheabovenamedstudent,requestthemedicationlisted
abovebegivenatschool.Iwillnotifytheschoolinwritingifthereisacancellationor
changeofthismedication.Ihavereadandunderstandthepolicyinformationonthe
backofthisform.Thisformshallalsopermittheschoolnursetoshareandrequest
relevanthealthinformationfrommyphysicianregardingtheadministrationofthis
medicationand/orsharerelevanthealthinformationtoschoolpersonnelasneeded.

Parent/GuardianSignature________________________________
Date_____________

4/2016


ProcedurefortheAdministrationofMedicationInSchool
TheNinevehHensleyJacksonSchoolshaveestablishedamedicationprocedureto
guideparentsandschoolpersonnel.
PrescriptionMedications
Medicationformmustbecompletedforprescribedmedicationsandonfilewiththe
schoolnurseforyourchildtobeallowedtotakeprescribedmedicationsduringschool
hours.Thiswrittenrequestform(onreverse)mustincludesignatureofthephysician
andparent/guardian.

Shorttermmedications(i.e.antibiotics)takenforfivedaysorless,theprescriptionbottle
isacceptableasthephysiciansorder.Signedparent/guardianisstillrequired.

Ifthemedicationisacontrolledmedication(Schedule1or2)parentsmustbringthis
medicationtothestudentsschool.

Foremergencymedicationssuchasasthmainhalersorepipens,studentsmaycarryin
theirpossessionandselfadministerasneeded,providedtheyhavebeenadequately
instructedintheirusebyaphysician(asdocumentedonthereversesideofthisform.)
andformisonfilewithschoolnurse.

Medicationsshouldbeadministeredtoschoolagechildrenathomewheneverpossible.

OvertheCounter
Anyoverthecountermedicationintendedfortheschoolyearmusthavephysiciannote
onfiledetailingreason,dose,andfrequency

Overthecountermedications(Tylenol,Ibuprofen,etc)musthaveaparentnoteandwill
notbegivenforlongerthanfive(5)daysunlessaphysicianhasprescribedtheOTC
medication.

Overthecounterpainreliefmedicationswillnotbegivenuntil2hoursafterthestartof
schoolor2hoursbeforedismissalunlessparent/guardiannotifiesschoolnurseofthe
reason.

TheschoolsDONOTprovidemedicationssuchasTylenol,Advil,etc.forstudentuse.

Aspirin,vitamins,herbal,homeopathic,essentialoils,andnaturalremediesarenot
given.

AllMedications
Studentsmaynotkeepanymedicationintheirpossession,lockerordesk,or
selfadministermedicationwithoutproperauthorizationfromschoolnurse.Doingsoisa
violationofschoolpolicy.

Allmedicationsareprovidedtotheschoolintheoriginalcontainerproperlylabeledwith
studentsname.Nomedicationsinplasticbags,envelopesand/orothercontainerswill
begiven.

Medicationswillnotbesenthomewithstudent.Schoolpersonnelwilldestroyall
medicationsnotpickedupbyparent/guardianwithinone(1)weekofschoolend.