Authorization for the Administration of Prescription Medication by School Personnel

The Connecticut State Law and Regulations requires a physician's / dentist's written order and parent's or guardian's authorization for a nurse or in her absence, the principal or her designee, to administer prescription medication to a student AS NEEDED during the current school year 2____ – 2____.

Prescription medication must be in the original pharmacy prepared container and labeled with name of child, name of drug, strength, dosage, frequency, physician's or dentist's name, and date of original prescription.

PHYSICIAN OR DENTIST ORDER                                      Date: ____________________________
Name of Student:  _________________________________________    Date of Birth: _____ / _____ / _____
                                                                                                                                          (Month / Day /  Year)
Address: __________________________________________________________________________________

Name of Medication: _____________________________________________

Dose, method of administration, and time of administration: _________________________________________
__________________________________________________________________________________________

Condition for which Medication is being administered during school hours: _____________________________

Date(s) medication is to be administered:           From: _______________        To: ________________

Relevant side effects to be observed, if any: ______________________________________________________

If there are side effects, plan for management: ____________________________________________________

Is this a Controlled Drug:          Yes _____       No _____        If, yes, provide DEA number: ____________

SELF-ADMINISTRATION FOR INHALERS ONLY (OPTIONAL): This student is capable of, and may be allowed to administer her own INHALER as prescribed.  (  )  YES   (  )  NO

PHYSICIAN'S / DENTIST’S NAME: ________________________________   Date: ____________________

PHYSICIAN'S / DENTIST’S SIGNATURE: ________________________Telephone No. ______________

PLEASE NOTE: A PHYSICIAN’S SIGNATURE IS REQUIRED YEARLY IN ORDER FOR YOUR CHILD TO RECEIVE PRESCRIPTION MEDICATION IN SCHOOL.

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I hereby request that school personnel administer the above medication, ordered by my licensed health care provider for my child. I must supply the school with the prescribed medication in the original container dispensed and properly labeled by a physician or pharmacist. I understand that this medication will be destroyed if it is not picked up within one week following termination of the order or one week beyond the close of school.

PARENT / GUARDIAN NAME _____________________________________ Date: ____________________

PARENT / GUARDIAN SIGNATURE:____________________________  Telephone No. ________________
                                               

Academy Of The Holy Family * 54 W Main Street *  P O Box 691 * Baltic CT * 06330-0691
* (School) (860) 822-9272 * FAX (860) 822-1318
Rev. 01.06