507.2E4 - Parental Authorization and Release Form for the Administration of Voluntary School Stock of Over-the-Counter Medication to Students

_________________________________           ___/___/___                 _________________    ___/___/___
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

 

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Parent/Guardian Address                                                                              Home Phone