5141.21 Form #1

_______________________ PUBLIC SCHOOLS

____________________________, Connecticut

   Authorization for the Administration of Medication by School Personnel

Connecticut State Law and Regulation require a written medication order of an authorized prescriber (physician, dentist, advanced practice registered nurse or physician's assistant) and parent's or guardian's authorization for a nurse to administer medications or in her absence, qualified personnel for schools (principal, teacher, occupational therapist, coach, licensed athletic trainer) to administer medications.  Medications must be in pharmacy prepared containers and labeled with name of child, name of drug, strength, dosage, frequency, authorized prescriber's name and date of original prescription.

Authorized Prescriber's Order

Name of Student: _____________________________________________________________Date: ________________________

Address: ___________________________________________________________________ Date of Birth: __________________

Condition for which drug is being administered during school hours, field trips, school readiness programs, before and after school programs, and during intramural and interscholastic events:

_______________________________________________________________________________________________________

Medication (name, dose and administration): _____________________________________________________________________

Medication shall be administered from ______________________________ to __________________________

Relevant side effects to be observed, if any _______________________________________________________________________

If there are side effects, plan for management: _____________________________________________________________________

[ ] I deem it medically appropriate for this patient to self-administer the medication __________________________________________
                                                                                                                                              Name of Medication

during the regular school day, field trips, school readiness, before and after school programs and/or intramural or interscholastic sports.

Authorized Prescriber's Signature ____________________________________________________________________________

Is this a Controlled Medication? ______________________________If yes, DEA number: _______________________________

Authorized Prescriber Name: __________________________________________________Telephone #: ___________________

Authorized Prescriber Signature: _______________________________________________ Date: _________________________

Address: _______________________________________________________________________________________________

Nurse/Qualified

Personnel for Schools: _______________________________________________________ Date: ________________________

Authorization by Parent/Guardian for the administration of the above medication by qualified school personnel and for the release of medical information from/to the above name medical practitioner.

Does your child have any allergies to medication?  [ ]  Yes  [ ]   No

If yes, what? ___________________________________________________________________________________________

Do you want medications given on early dismissal days?  [ ] Yes   [ ]  No

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 ____________________________

To School Personnel:

I hereby request that the above medication, order by the authorized prescriber for my child ___________________________________________ be administered by qualified school personnel.  I understand that I must supply the school with the prescribed medication in the original container dispensed and properly labeled by a physician or pharmacist and will provide no more than a three (3) month supply of said medication.

I understand that this medication will be destroyed if it is not picked up within one week following the termination of the order or one week beyond the close of school.

Parent/Guardian Name (print): ______________________________________________________________________________

Signature: _______________________________________________________Relationship to Child: ______________________

Address: ___________________________________________________ Telephone #: ________________________________