_____________________________      ___/___/___     _________________    ___/___/___
Student's Name (Last), (First) (Middle)      Birthday                   School                   Date

In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency. The following must occur for a student to self-administer medication for asthma medication, bronchodilator canisters or spacers, other airway constricting disease medication or to self-administer an epinephrine auto-injector:

• Parent/guardian provides signed, dated authorization for student medication self-administration.
• Parent/guardian provides signed, dated authorization from the student’s licensed health care professional  (person licensed under chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under chapter 152 or 152E and registered with the board of nursing, or a physician assistant licensed to practice under the supervision of a physician as authorized in chapters 147 and 148C containing the following:
  • Name and purpose of the medication,
  • prescribed dosage,
  • times or;
  • special circumstances under which the prescribed medication is to be administered.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.
• Authorization is renewed annually.  In addition,  if any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.

Provided the above requirements are fulfilled, the school shall permit the self-admiration of the prescribed medication by a student while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before-school or after-school care on school-operated property. If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

Pursuant to state law, the school district or its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or use of an epinephrine auto-injector by the student by the student as provided by law.

 

 

                                                                                                                                               
Medication                   Dosage             Route                                                   Time

 

                                                                                                                                               
Purpose of Medication & Administration /Instructions

 

                                                                                                            /           /          
Special Circumstances                                                    Discontinue/Re-Evaluate/
                                                                                                   Follow-up Date

                                                                                                            /     /       
Prescriber’s Signature                                                               Date

                                                                                                                                               
Prescriber’s Address                                                                 Emergency Phone

• I request the above named student possess and self-administer asthma, medication, bronchodilator canisters or spacers or other airway constricting disease medication(s) at school and in school activities according to the authorization and instructions.
• I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or for supervising, monitoring, or interfering with a student's self-administration of medication
• I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.
• I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.
• I agree the information is shared with school personnel in accordance with the Family Education Rights and Privacy Act (FERPA).
• I agree to provide the school with back-up medication approved in this form.
• Student maintains self-administration record.

 

                                                                                                            /           /          
Parent/Guardian Signature                                                         Date
(agreed to above statement)                              

                                                                                                                                               
Parent/Guardian Address                                                          Home Phone

                                                                                                                                               
                                                                                                   Business Phone

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               
Self-Administration Authorization Additional Information                                                

 

_________________________________           ___/___/___     _________________    ___/___/___
Student's Name (Last), (First),  (Middle)                 Birthday                    School                   Date

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide special health services listed. Electronic signatures meet the requirement of written signatures.
• The prescribed medication is in the original, labeled container as dispensed.
• The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, and date.
• Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.

 

                                                                                                                                                             
Prescribed Medication                        Dosage                         Route                           Time at School

 

Special Health Services and instructions, indicated:

                                                                                                                                                

                                                                                                                                               

            /           /          
Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services listed

 

                                                                                                /           /          
Prescriber’s Signature                                                   Date

And credentials (when indicated for health service delivery)

 

                                                                                                            /           /          
Parent/Guardian Signature                                                                     Date

                                                                                                                                   
Parent/Guardian Address                                                        Home Phone

 

_________________________________           ___/___/___                 _________________    ___/___/___ Student's Name (Last), (First), (Middle)               Birthday                       School                         Date

 

I request the above-named student (Parent/Guardian initial all that apply)

 

______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency. The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication id expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

 

__________________________________________________________________________________________
Prescribed Medication                               Dosage                        Route                           Time at School

 

 

______ Co-administer, participate in planning, management and implementation of special health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school. The information provided by the parent for health service delivery is confidential as provide by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year.

 

Special Health Services Delivery:
__________________________________________________________________________________

__________________________________________________________________________________

 

Procedures for abandoned medication disposal shall be in accordance with applicable laws.

__________________________________________      _______________________________
Prescriber’s Signature                                                            Date

and credentials (when indicated for health service delivery)

 

_________________________________________                    __________________________
Parent/Guardian Signature                                                                Date

_______________________________________                        __________________________
Parent/Guardian address                                                                 Home phone

_________________________________           ___/___/___                 _________________    ___/___/___
Student's Name (Last), (First), (Middle)               Birthday                       School                                  Date

 

The district supplies the following nonprescription, over-the-counter medications that are listed below. Generic brands may be substituted, (select all that apply:

 • Acetaminophen administered per manufacturer label

• Throat Lozenges administered per manufacturer label

• Other: ____________________ administered per manufacturer label (Please Specify)

 • Other: ____________________ administered per manufacturer label (Please Specify)

• Other: ____________________ administered per manufacturer label (Please Specify)

• Other: ____________________ administered per manufacturer label (Please Specify)

 

Voluntary school stock of nonprescription, over-the-counter medications are administered following these guidelines

: • Parent has provided a signed, dated annual authorization to administer of the nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature.

• The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.

• All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the counter medication.

• Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOT applicable.

• Nonprescription, over-the-counter medications approved by the Federal Drug Administration that require emergency medical service (EMS) notification after administration are NOT applicable.

 • Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the department and annual medication administration procedural skills check.

o Districts stocking the administration of a voluntary stock of nonprescription, over the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:

▪ when to contact the parent when a nonprescription medication, over the counter medication is administered;

 ▪ documentation of the administration of the nonprescription, over-the counter medication and parent contact;

 ▪ a limit to the administration of a school’s stock nonprescription, over-the counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school year;

▪ the development of an individual health plan for ongoing medication administration or health service delivery at school.

 

I request that the above-named student receive the voluntary stock nonprescription, over-the counter medications supplied by the school in accordance with the district guidelines and protocol.

 

__________________________________________                        _________________________
Parent Signature                                                                                            Date

 

__________________________________________                        _________________________
Parent/Guardian Address                                                                              Home Phone  

Some students who require special education need special health services in order to participate in the educational program.  These students will receive special health services in accordance with their individualized educational program.

 

A.    Definitions

"Assignment and delegation" - occurs when licensed health personnel, in collaboration with the education team, determine the special health services to be provided and the qualifications of individuals performing the health services.  Primary consideration is given to the recommendation of the licensed health personnel.  Each designation considers the student's special health service.  The rationale for the designation is documented.  If the designation decision of the team differs from the licensed health professional, team members may file a dissenting opinion.

"Co-administration" - the eligible student's participation in the planning, management and implementation of the student's special health service and demonstration of proficiency to licensed health personnel.

"Educational program" - includes all school curricular programs and activities both on and off school grounds.

"Education team" - may include the eligible student, the student's parent, administrator, teacher, licensed health personnel, and others involved in the student's educational program.

"Health assessment" - health data collection, observation, analysis, and interpretation relating to the eligible student's educational program.

"Health instruction" - education by licensed health personnel to prepare qualified designated personnel to deliver and perform special health services contained in the eligible student's health plan.  Documentation of education and periodic updates are on file at school.

"Individual health plan" - the confidential, written, preplanned and ongoing special health service in the educational program.  It includes assessment, planning, implementation, documentation, evaluation and a plan for emergencies.  The plan is updated as needed and at least annually.  Licensed health personnel develop this written plan with the education team.

"Licensed health personnel" - includes licensed registered nurse, licensed physician, and other licensed health personnel legally authorized to provide special health services and medications.

"Prescriber" - licensed health personnel legally authorized to prescribe special health services and medications.

"Qualified designated personnel" - persons instructed, supervised and competent in implementing the eligible student's health plan.

“Special health services" - includes, but is not limited to, services for eligible students whose health status (stable or unstable) requires:

• Interpretation or intervention,
• Administration of health procedures and health care, or
• Use of a health device to compensate for the reduction or loss of a body function.

"Supervision" - the assessment, delegation, evaluation and documentation of special health services by licensed health personnel.  Levels of supervision include situations in which licensed health personnel are:

• physically present.
• available at the same site.
• available on call.

 

B.     Licensed health personnel will provide special health services under the auspices of the school.  Duties of the licensed personnel include the duty to:

• Participate as a member of the education team.
• Provide the health assessment.
• Plan, implement and evaluate the written individual health plan.
• Plan, implement and evaluate special emergency health services.
• Serve as liaison and encourage participation and communication with health service agencies and individuals providing health care.
• Provide health consultation, counseling and instruction with the eligible student, the student's parent and the staff in cooperation and conjunction with the prescriber.
• Maintain a record of special health services.  The documentation includes the eligible student's name, special health service, prescriber or person authorizing, date and time, signature and title of the person providing the special health service and any unusual circumstances in the provision of such services.
• Report unusual circumstances to the parent, school administration, and prescriber.
• Assign and delegate to, instruct, provide technical assistance and supervise qualified designated personnel.
• Update knowledge and skills to meet special health service needs.

 

C.     Prior to the provision of special health services the following will be on file:

• Written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated.
• Written statement by the student's parent requesting the provision of the special health service.
• Written report of the preplanning staffing or meeting of the education team.
• Written individual health plan available in the health record and integrated into the IEP or IFSP.

 

D.    Licensed health personnel, in collaboration with the education team, will determine the special health services to be provided and the qualifications of individuals performing the special health services.  The documented rationale will include the following:

• Analysis and interpretation of the special health service needs, health status stability, complexity of the service, predictability of the service outcome and risk of improperly performed service.
• Determination that the special health service, task, procedure or function is part of the person's job description.
• Determination of the assignment and delegation based on the student's needs.
• Review of the designated person's competency.
• Determination of initial and ongoing level of supervision required to ensure quality services.

 

E.     Licensed health personnel will supervise the special health services, define the level of supervision and document the supervision.

 

F.     Licensed health personnel will instruct qualified designated personnel to deliver and perform special health services contained in the eligible individual health plan.  Documentation of instruction and periodic updates are on file at school.

 

G.    Parents will provide the usual equipment, supplies and necessary maintenance for such.  The equipment is stored in a secure area.  The personnel responsible for the equipment are designated in the individual health plan.  The individual health plan will designate the role of the school, parents, and others in the provision, supply, storage and maintenance of necessary equipment.