5141.21 Form #1 (alternate)

School District: ____________________________________ School: __________________________________Grade: _______________________

   Authorization for the Administration of Medicine by Authorized School Personnel

Connecticut State Law and Regulations 10-212(a) require a written medication order of an authorized prescriber, (physician, dentist, advanced practice registered nurse or physician's assistant) and parent/guardian written authorization, for the nurse, or in the absence of the nurse, qualified personnel for schools to administer medication.  Medications must be in the original properly labeled container and dispensed by a physician/pharmacist.

Authorized Prescriber's Authorization

Name of Student: ________________________________________________________ Date of Birth: ______________________________

Address:________________________________________________________________________________________________________

Condition for which drug is being administered: ___________________________________________________________________________

Drug name: _________________________________ Dose: ____________________ Route: ______________________________________

Time of Administration: __________________________________________ If PRN, frequency: ____________________________________

Relevant side effects:  [ ]  None expected     [ ]   Specify: ____________________________________________________________________

Allergies:  [ ]  No   [ ]  Yes (specify): ___________________________________________________________________________________

Medication shall be administered from: _____________________________ to __________________________________
                                                                        Month/Day/Year                                         Month/Day/Year

Authorized Prescriber's Name/Title: ___________________________________________________________________________________
                                                                                                       (Type or Print)

Telephone: ____________________________________________________ Fax: _______________________________________________

Address:_________________________________________________________________________________________________________                                                

Authorized Prescriber's
Signature: _____________________________________________________ Date: ______________________________________________                                                  Use for Authorized Prescriber's Stamp

Parent/Guardian Authorization

I hereby request that the above ordered medication be administered by school personnel.  I understand that I must supply the school with no more than a three (3) month supply of medication.  I understand that this medication will be destroyed if not picked within one (1) week following termination of the order or the last day of school, whichever comes first.

Parent/Guardian Signature: ____________________________________________________________ Date: __________________________

Parent's/Guardian's Home Phone #: _____________________________________________________ Work #: _________________________

_________________________________________________________________________________________________________________________________________________________________________

Self-Administration of Medication Authorization/Approval

Self-administration of medication may be authorized by the authorized prescriber and parent/guardian and must be approved by the school nurse in accordance with Board policy.

Authorized prescriber's authorization for
self-administration:   [ ] Yes     [ ]  No  ______________________________________________________________________________
                                                              Signature                                                                                                                 Date

Parent/Guardian authorization for
self-administration:  [ ]  Yes    [ ]  No  ______________________________________________________________________________
                                                              Signature                                                                                                                 Date

School nurse approval for
self-administration:  [ ]  Yes    [ ]   No ______________________________________________________________________________
                                                               Signature                                                                                                                Date