Medication permission form and administration policy 2

Newton South High School Nurse
Tel: 617-559-6575 Fax: 617-559-6701
This form must be completed by a health care provider and parent before any medication (over-the-counter or
prescription) can be administered at school. (M.G.L. Chapter 112 § 80)

Student name __________________________ School ___________Grade: ___ D.O.B.: ____________ M F
HEALTH CARE PROVIDER: Please complete a separate form for each medication to be administered at school.
Medication _________________________________ Dose __________________ Route _________________
Frequency ______________________________ Time(s) to be given at school_________________________
Possible side effects: ________________________________________________________________________
Special Instructions: ________________________________________________________________________
Date of order: _____________________________ Discontinuation date: _______________________________ Diagnosis ________________________________ Drug/Food Allergies: _______________________________ Name of licensed prescriber: ___________________________________ Title __________________________ Signature of licensed prescriber: _____________________________________________Date: _____________
Address: ___________________________________________________ Phone:________________________

Consent for self administration:
The student has been instructed to self administer medication and may do so
at school. Yes____ No____ (The school nurse must determine it to be safe and appropriate.)

Print Name: ________________________________________ Relationship to student ___________________
Please list all other medications. _______________________________________________________________ I, the undersigned parent or guardian, give permission to the school nurse (or school personnel designated by the school nurse) to administer the above medication to my child or to supervise my child in taking the above medication if approved to do so by the school nurse. I authorize the school nurse to share information about such medication administration as the school nurse deems necessary for the health and safety of my child. I agree to release, indemnify and hold harmless the City of Newton, the Newton School Committee and their employees and agents from and against any claim either I or my child may have as a result of any act or omission which may arise out of this authorization. Signature of Parent / Guardian ______________________________________________ Date ______________ Phone numbers: Home ___________________ Work ___________________Cell _______________________ Field Trip Plan: _________________________________________________________________________________________ Signature of School Nurse: ___________________________________________________________________ School Medication Administration Policy: see next page
The school nurse is responsible for the administration of all medications. Medication administration can be delegated to other trained personnel under certain circumstances. The Medication Permission Form (see other side) must be received by the school nurse prior to any
medication administration.

The following statements highlight the main points of the policy. The entire policy is available in each health room, at the Health and Human Services Department and on the web site Medication administration should be scheduled at times other than during school hours, whenever possible. All medication must be delivered by the parent/guardian or designated adult. Only a 30-day supply of medication will be accepted at any time. All medication must be delivered in a pharmacy or manufacturer labeled container. The pharmacy-labeled container can be used in lieu of a health care provider's order only for short-term medications, i.e. those medications to be given for 10 school days or less. Self medication can be allowed under certain circumstances after consultation with the school nurse. The school nurse must be notified in advance if medication is scheduled to be administered during a
field trip.
This Medication Permission Form must be renewed at the beginning of each school year.
Over-the-counter medication will be treated the same as prescription medication.
This means that medications such as Tylenol, Benadryl, Advil, etc., require a written order from a health care provider and a supply of the medication provided by the parent. Medication Quantity Received by School:
Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________ Amnt: __________ Date: __________ Exp. Date: __________


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