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