Policy Manual

For access to the form and Controlled Substance Log Sheet, click here.

Policy JLCD-R

**Parental requests for medication administration at school must be accompanied by a written order from the physician/health care provider or dentist, substantiating the fact that the administration of a particular medication during the school day is medically necessary for the pupil’s health and attendance in school.

**All medication(s), including over the counter products must be in ORIGINAL containers. 

In addition, prescription medication must have a clear label identifying the student, medication, dose, time of  administration and prescribing health care provider. Your pharmacist can provide an additional labeled container for  use at school. 

**Parent/guardian must personally provide school with up to one week’s dosage unless other arrangements have been made with the school nurse.

**It shall be the parent’s responsibility to notify the school of any changes or discontinuation of a prescribed medication  that is being administered to the child in school.

Student’s Name: _______________________________ School:________________________ Grade:______ 

Name of Medication: ______________________________________________________________________  

Medication Description: Circle one (capsule, tablet, gel cap, liquid, drops, inhalants) 

If tablet: Shape:____________ Markings (letter/#s): _____________ Color: __________  

Dosage:_________________________ Time to be given: _________________________  

Reason for Medication: _____________________________________________________________________ 

Side effects that school staff should be aware of? _________________________________________________ 

Termination date (not beyond the current school year): _____________________________________________  

Prescribing Health Care Provider Signature: __________________________________________________ Date: _____________________ Phone #: __________________________ Fax #: _______________________

Medication Removal 

Only a limited, necessary supply of medication(s) can be kept in the school. Parent or legal guardian must remove Medication(s) no longer required. Amy medication not removed by the last day of school each year will be destroyed.

Informed Consent of Parent/Legal Guardian 

 *I hereby request that school department personnel administer the above medication to my child. I am aware that this medication may be administered by medical or non-medical school personnel.

 *I give my permission for the school nurse to contact the above named prescribing physician to obtain information about the  medication and the administration schedule. I give permission for the school nurse to share information with the doctor about the  effects of the medication on my child’s learning. 

 *I understand that information regarding the student’s medication may be shared with appropriate school personnel.

_________________________________________________________________________________________ 

Parent/Legal Guardian Signature - Home Phone Number - Work Phone Number - Date 

Revised: November 19, 2002

Adopted: December 9, 2002  

Revised: March 9, 2020  

*Please excuse any formatting errors.