SCHOOL MEDICATION AUTHORIZATION FORM

Ut a h De p a r t m e n t o f He a l t h / Ut a h S t a t e B o a r d o f E d u c a t i o n

In  A c c o r d a n c e  w i t h  U C A  5 3 A - 11 - 601

(This form is not required if Local Education Agency (LEA) has developed their own medication authorization form/log with the same information included.)

Date:

School:

Student

Picture

STUDENT INFORMATION
St u d e n t : Sch o o l : DO B : Gr a d e :
Pa r ent : Pho ne: Em ai l :
P re s c ri b e r N a m e : Pho ne: Fax:
Sch o o l N u r s e : Sch o o l P h o n e : Fax:
Pa r ent : complete the above section, read and sign below, obtain signature from Health Care Provider and return to school nurse.

As parent/guardian I request the medication(s) listed below be given to my student during regular school hours.

D I understand medication will be administered by trained school employee volunteers.

D I understand a new medication authorization form will be required each school year, and whenever there is a dosage change.

D I understand parent or guardian is responsible for maintaining necessary supplies, medications, and equipment.

D I understand prescription medication must be transported to and from school by an adult*.

D I understand all medication, both prescription and over-the-counter,  must be in the current original pharmacy container and

label, with the child’s name, medication name, administration time, dosage, and health care provider’s name.

D I understand over-the-counter medication must be in the original manufacture container.

D I understand the information contained in this order will be shared with school staff on a need-to-know basis.

D I understand it is my responsibility to notify the school nurse of any change in my student’s health status, care or medication

order.

I give permission for my child’s healthcare provider to share information with the school nurse for the completion of this order.

Parent  S i g na t ur e :                                                                                               Date:                                     

MEDICATION INFORMATION
If a request is being made for school staff to administer asthma medication, epinephrine auto-injector, diabetes medication, or seizure rescue medication, an additional specific form(s) will be required, and must be signed by the parent and physician, and kept on file at the school.  These supplemental forms will also be required for students who carry and self-administer asthma medication, epinephrine auto-injectors, and diabetes medications.
Na m e o f M e d i c a t i o n In d i c a ti o n / D i a g n o s i s Do s a g Rou t e Ti m e Si d e E f f e ct s
           
           
           
Additional Instructions to the school:
Medication will be kept:  D In the office            D In the classroom         D Student carries*         D Other:                                                             
SIGNATURE This order can only be signed by an MD/DO; Nurse Practitioner, Certified Physician’s Assistant or a provider with prescriptive practice. 

The above named student is under my care.  It is medically necessary for medication administration while student is under the

control of the school.

D It i s medically appropriate for the student to self-carry* this medication, when able and appropriate, and be in possession of this medication and supplies at all times (see statement above under Medication Information). This student has been trained to self-administer the medication and is capable of doing this safely.

D It i s n o t medically appropriate to carry and self-administer this medication. Please have the appropriate/designated school personnel maintain this student’s medication for use if needed.

Prescriber Signature:                                                                                       Date:                                                  

Sch o o l St af f N am e Si gn at u r e Da t e
Principal Name:    
School Nurse Name:    

pdfMedauthform2017.pdf

 

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