Right click here to print this page.
Medication Authorization Form
2/14/2014

Review of Greenville Area School District’s Medication Policy

We know there may be times throughout your child’s school year that he or she may need to take medications, Your child’s health is of primary importance and we want to make sure that he or she is taken care of when in school. Because the nurse can not be in every school and classroom all the time, we ask your help and cooperation with dispensing of any medication.

Primarily, we ask that you try to arrange the medication dosages so that you, the parent and/or guardian, can give your child’s medication prior to school or after school; or if needed, that you will be able to come to school to actually dispense it personally,

Although, the District strongly recommends that medication be given at home, we realize that the health of some children requires that they receive medication while at school. Medication (prescriptive or non-prescriptive) will only be given at school when the nurse receives a written prescription form from your child’s treating physician.

 

· The school district will no longer be administering Tylenol, Motrin, Mylanta or any other over-the –counter medications unless there is a written prescriptive order from your child’s physician. If you think that your child will need to take medications at any time throughout the school year please obtain this written order from your doctor.

 

· Along with the physician’s written order the parent must complete the District’s “Authorization for Administration of Medication” form. The school district’s “Authorization of Medication” form with specific directions from the treating physician and written authorization from the parent must be provided for all medication. This form is available in the Student’s Handbook and the Nurse’s Office.

· All medications must be brought to school by the parent/guardian or responsible adult. No medications should be sent with the child to school under any circumstances. No medications are allowed on the buses.

 

· Medications such as asthmatic inhalers, insulin injections, and bee sting kits may be required by an individual students for emergency situations for self administration only if the student is deemed competent by the parent, doctor, and the school nurse to perform self administration adequately. This also requires a written order from the treating physician and must be given to the school nurse.

This brief description of our guidelines are instituted for the safety of your children and the entire school community. If you would like a complete copy of the “Guidelines for Use of Medication,” please notify the school nurse at Hempfield Elementary, East Elementary, or the High School.

GREENVILLE AREA SCHOOL DISTRICT

9 DONATION ROAD

GREENVILLE, PA. 16125

 

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION FORM

 

The Greenville School District recognizes that parents have the primary responsibility for the health of their children. Although, the district strongly recommends that medication be given at home, it realizes that the health of some children requires that they receive medication while at school. When prescriptive or over-counter-medication absolutely must be given during school hours, certain procedures must be followed. The attached form must be completed by the physician and parent and accompany the medication. A new medication form must be completed for each school year.

1. Written instructions, signed by the parent or guardian and a physician as required will include:

SECTION I; IS TO BE COMPLETED BY THE PARENT

a. Child’s name

b. Home phone number

c. School building

d. Student’s grade

e. Student’s homeroom

SECTION II; IS TO BE COMPLETED BY THE PARENT AND PHYSICIAN FOR ANY MEDICATION GIVEN AT SCHOOL –PRESCRIPTIVE OR NON-PRESCRIPTIVE

a. Name of medication or nature of treatment

b. Diagnosis/condition

c. Purpose of medication/treatment

d. Time to be administered

e. Dosage with any specific instructions

f. Possible side effects

g. Allergies

h. Procedure to follow if reaction should occur

i. Termination date for administering medication/treatment

j. Signature and address of physician with date of signature

k. Signature of parent with the date of signature

2. The school nurse or school district designee will:

a. Inform his/her supervisor and the teacher of the medication/treatment

b. Keep a record of the administration of the medication/treatment

c. Keep medication in a locked cabinet

d. Return unused medication to ONLY the parent or guardian

3. The parent or guardian will:

a. Ensure that the medication is delivered by the parent, guardian, or responsible adult. CHILDREN ARE NOT PERMITTED TO BRING MEDICATION WITH THEM TO SCHOOL OR ON THE BUS. In the absence of the nurse the medication will be given to the secretary or teacher.

b. Send the medication in a labeled container from the pharmacy if it is a prescriptive medication. The prescribed medication must be accompanied by the medication form completed by the physician and parent. This label should contain the following information:

1. Date and student’s name

2. Doctor’s name and address

3. Name of medication, dosage time and how it is to be stored

c. If the medication is non-prescriptive (over-the-counter) – the medication must be in its

original container with the original label accompanied by the medication form completed

by the physician and parent.

d. The parent or guardian will assume responsibility for informing the school nurse or school

district designee of any change in the child’s health or change in medication/treatment. A new form is required with each change in medication/treatment.

 

GREENVILLE AREA SCHOOL DISTRICT

 

MEDICATION AUTHORIZATION FORM FOR ADMINISTERING PRESCRIPTIVE AND NON-PRESCRIPTIVE MEDICATIONS TO STUDENTS

 

The Greenville School District recognizes that parents have the primary responsibility for the health of their children. Although, the district strongly recommends that medication be given at home, it realizes that the health of some children requires that they receive medication while in school. When medication prescriptive or non-prescriptive (Tylenol, Motrin, etc.) must be given during school hours, certain procedures must be followed.

Instructions: To the nurse or school district designee for the medication or treatment required during the school day.

 

SECTION I

 

Name of Student_________________________ Home Phone______________________________________________________

 

School_________________________________Grade___________Teacher____________________________________________

 

SECTION II

 

To be completed by the physician and parent for any medication given at school (prescriptive or non-prescriptive).

 

Name of medication or nature of treatment______________________________________________________________________

 

___________________________________________________________________________________________________________

 

Purpose of medication/treatment_______________________________________________________________________________

 

___________________________________________________________________________________________________________

 

Date medication /treatment is to begin__________________________Date ceases______________________________________

 

Dosage_______________________________________________Time of dosage_________________________________________

 

Special instructions (if any):___________________________________________________________________________________

 

___________________________________________________________________________________________________________

 

Procedure to follow if reaction should occur:_____________________________________________________________________

 

___________________________________________________________________________________________________________

 

Person to contact_____________________________________Phone__________________________________________________

 

Does the medication require refrigeration? (Circle one) Yes No

 

 

Please return this form with the medication

Hempfield fax number - 588-5036 , East Elem. Fax number is 588-1319, High School Fax is 588-4397

 

 

Signature of Physician Date

 

I hereby authorize the medication/treatment listed above to be administered to my child. Furthermore, I release the Greenville School District and its employees from liability claims which may be brought as a result of district employees carrying out their assigned duties in good faith. I hereby certify the information provided to the medical staff of the Greenville Area School District concerning the administration of the medication to the above student is true and correct.Signature of Parent/Guardian Date