ALABAMA STATE DEPARTMENT OF EDUCATION

SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION School Year:

STUDENT INFORMATION School:

Student's Name: Date of Birth:

/

Teacher:

Grade:

Age:

/

PRESCRIBER AUTHORIZATION

(To be completed by licensed healthcare provider)

Route:

Medication Name:

Dosage:

Frequency/Time(s) to be given:

Start Date:

Reason for taking medication: Potential side effects/contraindications/adverse reactions: Treatment order in the event of an adverse reaction: SPECIAL INSTRUCTIONS: Is the medication a controlled substance? Is self- medication permitted and recommended? If "yes" I hereby affirm this student has been instructed On proper self-administration of the prescribe medication. Do you recommend this medication be kept "on person" by student? Printed Name of Licensed Healthcare Provider:

pounds

Weight:

0 No known drug allergies---if drug allergies list:

Yes Yes

/

/



No No



No



Yes Phone: (

Stop Date:

/

/







Fax:

) Date:

Signature of Licensed Healthcare Provider:

PARENT AUTHORIZATION I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to administer or to delegate to unlicensed school personnel the task of assisting my child in taking the above medication in accordance with the administrative code practice rules. I understand that additional parent/prescriber signed statements will be necessary if the dosage of medication is changed. I also authorize the School Nurse to talk with the prescriber or pharmacist should a question come up with the medication. Prescription Medication must be registered with School Nurse or trained Medication Assistants. Prescription medication must be properly labeled with student's name, prescriber's name, name of medication, dosage, time intervals, route of administration and the date of drug's expiration when appropriate. Over the Counter Medication must be registered with the School Nurse or Trained Medication Assistant, OTC's in the original, unopened and sealed container. Local Education Agency Policy for OTC medication to be followed:

Parent's/Guardian's Signature:

/ /

Date:

Phone: ( )

SELF-ADMINISTRATION AUTHORIZATION To be com • leted ONLY if student is authorized to com lete self-care b licensed healthcare rovider.

I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the school, the agents of the school, and the local board of education against any claims that may arise relating to my child's selfadministration of prescribed medication(s). Signature of Parent:

Date:

/

Phone: ( ) revised 5/2014

school medication prescriber parent authorization form.pdf ...

Page 1 of 1. SELF-ADMINISTRATION AUTHORIZATION. To be com • leted ONLY if student is authorized to com lete self-care b licensed healthcare rovider.

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