Medication Administration at School:  Required Forms

For Diabetic Care:

• Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
• Diabetic Medical Management Plan (or specific medical orders from Endocrinologist (diabetes doctor)
  • MUST BE SIGNED BY HEALTHCARE PROVIDER

For Asthma:

• Asthma Action Plan
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
• Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
  • The inhaler must be in the box with label attached as received from the pharmacy
• Self Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
  • If the inhaler is to remain with the student, this form MUST be completed and signed by HEALTHCARE PROVIDER

For Allergies:

For ALL Allergies:

• Administration of Medication Form
  • For Epi-Pen/Auvi-Q
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
• Complete Allergy & Anaphylaxis Action Plan
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
• Self Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
  • If Epipen is to remain with the student, this form MUST be completed and signed by HEALTHCARE PROVIDER

For FOOD Allergies:

• Medical Statement for Children Requiring Special Meals
  • Required if school is to withhold certain foods that contain student's allergies
  • Required by state law in order to exclude foods
  • MUST BE SIGNED BY HEALTHCARE PROVIDER

For Seizures:

• Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
• Seizure Action Plan
  • MUST BE SIGNED BY HEALTHCARE PROVIDER

For Prescription Medications:

• Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
  • Medication must be brought in its original container
  • Label on the outside of the bottle must be from the pharmacy with the student's name and instructions on how to administer medication.
  • Label should be legible and in English

For Over-the-Counter Medications:

• Completed Healthy Kids Registration Form
  • Permission must be given on the registration form for school nurse services which lists OTC's that are allowed to be given.

Other Health needs or concerns (tracheostomy, g-tube feeding, oxygen, catheters) – Contact your School Nurse ASAP