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.
