Medication Administration at School:  Required Forms

For Diabetic Care:

• Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
• Diabetic Medcial 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
  • ​​​​​​​NOTE:  If inhaler is to remain with the student, "YES" must be checked in the area which discusses "may carry or self-administer"
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
  • Inhaler must be in box with label attached as received from the pharmacy

For Allergies:

For ALL Allergies:

• Administration of Medication Form
  • For Epi-Pen
  • NOTE:  If Epi-Pen is to remain with student, "YES" must be checked in the area which discusses "may carry or self-administer"
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
• Complete Allergy Action Plan

For FOOD Allegeries:

• Family Food Allergy Health History Form
• 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

Other Allergies:

• Emergency Care Plan-Bee Sting Allergy

For Seizures:

• Administration of Medication Form
  • MUST BE SIGNED BY HEALTHCARE PROVIDER
  • NOTE:  School staff will NOT be allowed to administer Klonipin, only administered by school nurse when he or she is at school.
• Seizure Emergency Plan of Action
  • ​​​​​​​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 student's name and instruction on how to administer medication.
  • Label should be legible and in English

For Over-the-Counter Medications:

• HKC - Notification Letter Regarding Over-The-Counter Medications (for August 2018 to December 2018)
• Administration of Medication Form
  • ​​​​​​​MUST BE SIGNED BY HEALTHCARE PROVIDER

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

• Submit specific Doctor orders
  • ​​​​​​​MUST BE SIGNED BY HEALTHCARE PROVIDER