Authorization to Administer Medication

Which Must Be Taken During School Hours

Date: ___________ Student’s Name: ____________________________ Grade/House/Teacher: ____________

Name of Medications: ______________________________ Pharmacy: ________________________________

Prescribing Physician: ______________________________ Telephone: _______________________________

Reason for Medication: ______________________________________________________________________

Dosage: ______________________________ Time(s) to be Administered: _____________________________

Possible side effects and safety procedures: ______________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date

Prescribing physician’s signature or prescription label

_______________________________________________ ______________________________

Medication Removal

At the end of the school year or the last day of student’s enrollment, I choose the following method of medication disposal:

¨ Parent will remove medication from school

¨ Send the medication home with my child

¨ School nurse may dispose of the medication

I understand that the above medication may be administered by any staff member who is the principal’s designee. This may include a school nurse or a medically unlicensed person designated by the principal as allowed by law.

Permission to Contact Prescribing Physician

I give my permission for the school nurse to contact the above named prescribing physician to obtain information about the medication and the administration schedule. I give my permission for the school nurse to share information with the doctor about the effects of the medication on my child’s learning.

Witness

Work Phone

Home Phone

Parent or Legal Guardian’s Signature

___________________________________________ ______________________ _______________________

Date

___________________________________________ ______________________________________________

Instructions for Parent/Guardian

For Authorization of Medication

It is the policy of the Portland Public Schools that only essential medications will be administered to students in school. Whenever possible, the schedule of medication administration would allow a student to receive all prescribed doses at home.

If a student needs medication, which has been prescribed by a physician, during school hours, please follow these instructions:

1. Complete the Authorization to Administer Medication form and return it to the school office with the medication. A physician’s prescription (current prescription label or signed note) will be required for prescription drugs and may be required for over the counter drugs.

2. Send the medication to the school office in an original, unbreakable container that is properly labeled with the name of the medication, date, dosage, time(s) to be administered and the name of the student who is to receive it.

3. Medication sent to the school should not exceed the dosage for one day unless prior arrangements have been made with the school nurse.

4. Refer to the complete Portland Public Schools Medication Policy (JLCD) as necessary or call the school nurse who serves your child’s school.