Title POLICY NO POSSESSION/USE OF ASTHMA INHALERS

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1 Policy No KEYSTONE OAKS SCHOOL DISTRICT Section PUPILS Policy Guide Title POSSESSION/USE OF ASTHMA INHALERS Adopted DECEMBER 9, 2009 Revised POLICY NO Authority The Board shall permit students to possess asthma inhalers and to self-administer the prescribed medication used to treat asthma when such is parent-authorized. Possession and use of asthma inhalers by students shall be in accordance with state law and Board policy. 2. Definitions Asthma inhaler shall mean a prescribed device used for self-administration of shortacting, metered doses of prescribed medication to treat an acute asthma attack. Self-administration shall mean a student's use of medication in accordance with a prescription or written instructions from a physician, certified registered nurse practitioner or physician assistant. 3. Guidelines Before a student may possess or use an asthma inhaler on school property during school hours or during school-related activities, the Board shall require the following: Page 1 of 5

2 POLICY NO A written request from the parent/guardian that the school complies with the order of the physician, certified registered nurse practitioner or physician assistant. 2. A written statement from the physician, certified registered nurse practitioner or physician assistant, on "Form B-1, as attached, that states: a. Name of the drug; b. Prescribed dosage; c. Times medication is to be taken; d. Length of time medication is prescribed; e. Diagnosis or reason medication is needed, unless confidential; f. Potential serious reaction or side effects of medication; g. Emergency response; h. If child is qualified and able to selfadminister the medication. 3. A statement from the parent/guardian, on "Form B-2," as attached, acknowledging that neither the School District nor any of its employees are responsible for ensuring the medication is taken and relieving the District and its employees of responsibility for the benefits or consequences of the prescribed medication. Page 2 of 5

3 POLICY NO The student shall be made aware that the asthma inhaler is intended for his/her use only and may not be shared with other students. The student shall notify the school nurse immediately following each use of an asthma inhaler. Violations of this policy by a student shall result in immediate confiscation of the asthma inhaler. The District reserves the right to require a statement from the physician, certified registered nurse practitioner or physician assistant for the continued use of a medication beyond the specified time period. Permission for possession and use of an asthma inhaler by a student shall be effective for the school year for which it is granted and shall be renewed each subsequent school year. A student whose parent/guardian completes the written requirements for the student to possess an asthma inhaler and self-administer the prescribed medication in the school setting shall demonstrate to the school nurse the capability for selfadministration and responsible behavior in use of the medication. To self-administer medication, the student must be able to: 1. Respond to and visually recognize his/her name; 2. Identify his/her medication; 3. Demonstrate the proper technique for selfadministering medication; Page 3 of 5

4 POLICY NO Sign his/her medication sheet to acknowledge having taken the medication. 5. Demonstrate a cooperative attitude in all aspects of self-administration. 4. Delegation of The Superintendent or designee, in conjunction Responsibility with the school nurse(s), shall develop procedures for student possession of asthma inhalers and selfadministration of prescribed medication. The District shall annually inform staff, students and parents/guardian about the policy and procedures governing student possession and use of asthma inhalers. When an asthma inhaler is initially brought to school by a student, the school nurse shall be responsible to complete the following: 1. Obtain the required written request and statements from the parent/guardian and physician, certified registered nurse practitioner or physician assistant, which shall be kept on file in the office of the school nurse; 2. Review pertinent information with the student and/or parent/guardian, specifically the information contained on the statement submitted by the physician, certified registered nurse practitioner or physician assistant; 3. Determine the student's ability to selfadminister medication and the need for care and supervision; Page 4 of 5

5 POLICY NO Maintain an individual medication lot for all students possessing asthma inhalers. References: School Code - 24 P.S. Sec. 1401, State Board of Education Regulations 22 PA Code Sec Page 5 of 5

6 KEYSTONE OAKS SCHOOL DISTRICT 1000 Kelton Avenue Pittsburgh PA FORM B-1 AUTHORIZATION FOR THE POSSESSION AND USE OF AN ASTHMA INHALER BY STUDENT Dear Physician/Certified Registered Nurse Practitioner/Physician's Assistant: The parents of the below-named student have requested that the Keystone Oaks School District permit said student to possess and use (self-administer) an asthma inhaler on school property during school hours or during school-related activities. It is the policy of the Keystone Oaks School District to request an Authorization from a student's physician/certified registered nurse practitioner/physician's assistant as a condition of a student's possession and use of an asthma inhaler. Kindly provide the information requested below. Attach additional sheets if necessary. Thank you for your cooperation. Sincerely, School Nurse Signature Student Name Age Date of Birth Mother's Full Name Mother's Address Mother's Home Phone Work Phone Father's Full name Father's Address Father's Home Phone Work Phone 1 of 2 B-1

7 Name of asthma medication being prescribed for use with asthma inhaler Dose Times when asthma medication is to be taken Diagnosis/reason medication is needed (unless confidential) Potential serious reaction(s) or side effect(s) of the asthma medication and the emergency response thereto Whether the student is qualified and able to self-administer the medication Name of the physician/certified registered nurse practitioner/physician s assistant prescribing the asthma inhaler Telephone number of physician/certified registered nurse practitioner/physician s assistant Names of other physicians or health care practitioners providing treatment to the student Other medication prescribed or suggested for use by the student Other medications currently taken by the student, whether prescription medication or nonprescription medication, and regardless of when and where taken I (We) acknowledge that in complying with this Request and Authorization, and in accordance with the current order of the physician/certified registered nurse practitioner/physician s assistant, I (we) are releasing and indemnifying the School District, its officers, agents and employees, from any and all responsibility for the benefits or consequences of the abovedescribed medication, including responsibility for ensuring the medication is taken, PROVIDED, HOWEVER, that the parent(s) of a protected handicapped student as that term is defined within the Pennsylvania Department Regulations found at 22 PA Code Chapter 15, shall not be required to acknowledge or execute such a Release or Indemnification Agreement. Parent(s) Signature Date 2 of 2 B-1

8 KEYSTONE OAKS SCHOOL DISTRICT 1000 Kelton Avenue Pittsburgh PA FORM B-2 PARENT REQUEST AND AUTHORIZATION FOR THE POSSESSION AND USE OF AN ASTHMA INHALER BY STUDENT I (We), the parent(s) of the student listed below, hereby request and authorize the Keystone Oaks School District to permit said student to possess and use (self-administer) an asthma inhaler on School District property during the school day and/or during school-related activities in compliance with Authorization For Possession And Use Of An Asthma Inhaler signed by the student's physician/certified registered nurse practitioner/physician's assistant (Form B-1), which is being submitted herewith. I understand and acknowledge that my child will not be permitted to possess or use an asthma inhaler on School District property during the school day or during school-related activities unless both forms are completed, signed and received by the School District, AND the student satisfactorily demonstrates to the school nurse that he/she can self-administer the inhaler by meeting all of the criteria for selfadministration set forth in District Policy No I further understand and acknowledge that failure of my child to comply with any provision(s) of District Policy No shall result in immediate confiscation by District personnel of the asthma inhaler. Student Name Age Date of Birth Mother s Full Name Mother s Address Mother s Home Phone Work Phone Father s Full Name Father s Address Father s Home Phone Work Phone 1 of 2

9 Name of asthma medication being prescribed for use with asthma inhaler Dose Times when asthma medication is to be taken Diagnosis/reason medication is needed (unless confidential) Name of physician/certified registered nurse practitioner/physician s assistant prescribing the asthma inhaler Telephone number of physician/certified registered nurse practitioner/physician s assistant Names of other physicians or health care practitioners providing treatment to the student Other medications prescribed or suggested for use by the student Other medication currently taken by the student, whether prescription medication or nonprescription medication, and regardless of when and where taken. I (We) acknowledge that in complying with this Request and Authorization, and in accordance with the current order of the physician/certified registered nurse practitioner/physician s assistant, I (we) are releasing and indemnifying the School District, its officers, agents and employees, from any and all responsibility for the benefits or consequences of the abovedescribed medication, including responsibility for ensuring the medication is taken, PROVIDED, HOWEVER, that the parent(s) of a protected handicapped student as that term is defined within the Pennsylvania Department Regulations found at 22 PA Code Chapter 15, shall not be required to acknowledge or execute such a Release or Indemnification Agreement. Parent(s) Signature Date 2 of 2 B-2

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