Information Regarding the Student with an Allergy Student s Name Grade Homeroom Date Physician s Name Physician s Phone # Type of Allergy (Food, Bee, Wasp, Latex, Other: Specify): Type of Reaction: For a Food Allergy, does the student have a reaction to being touched by the allergen? Yes No If Yes, sit at the Allergy Free Table for the Student s Safety? (Elementary) Yes No Is your child s reaction usually immediate or delayed? If delayed, how long until reaction usually occurs? Have you been told by the doctor that your child is subject to a severe systemic reaction and needs immediate treatment? Yes No Has your child ever been treated by a doctor or hospital for a generalized reaction or difficulty breathing due to this allergy? Yes No If Yes, describe: Does your child need to be given emergency medicine for these reactions? Yes No If Yes, list medication(s)*: Please list desired first aid procedures: Further comments or additional instructions: *Please keep in mind that Pennsylvania State Law requires medication orders from a licensed prescriber if medications are required at school. Remember, all medications must be in their original container. It is important to keep the school nurse informed regarding any changes in medication or any of the above information. Thank you for your cooperation in this matter. Parent / Guardian Signature Date Rev. 2011
Authorization for Medication to be Given at School ** If the following is for an Inhaler or Epinephrine Injector: parent must also complete and submit the corresponding forms: Student s Name: Grade Date of Birth Parent s Home Phone: Emergency Phone: Health Care Provider s Name Phone: I request that the school comply with the medication order below. I agree to comply with the regulations listed on the reverse side of this form. I also hereby authorize and request that my child be assisted in taking the medication(s) below, by the persons listed on the reverse side of this form. I relieve the school district and its employees of any responsibility for the benefits or consequences of this medication that is physician, dentist, nurse practitioner or physician assistant prescribed and parent / guardian authorized. Parent / Guardian Signature Date B. The following section is to be completed and signed by the Physician, Dentist, Certified Nurse Practitioner, or Physician s Assistant prescribing the medication: Diagnosis for which medication is to be given: Name of Medication to be given: EPINEPHRINE INJECTOR : TYPE &Dose: Frequency, Route, Time to be given: If ordered PRN describe indications: How soon can it be repeated? List Significant Side Effects: Length of time treatment is to take place:* *School Policy requires a new order for each school year. Inhalers: Student is qualified, able to carry, and self-administer the Inhaler: yes no Epinephrine: Student is qualified, able to carry, and self-administer the Epinephrine: yes no If Inhaler / Epinephrine is not effective in relieving symptoms, state further plan of action: Licensed Prescriber s Signature Date
Administering Medications to Students Pennsylvania State Law governs the administration of all medications, including over-the-counter medications. The law forbids a nurse to administer any medication without a licensed prescriber s written order and signed permission by the parent or guardian. The Plum Borough School District recognizes that when students health needs make it necessary for medication to be taken during school hours, certain procedures must be followed. 1. Written Order - Prescription medications, over-the-counter medications, nutritional supplements, or herbal supplements will not be administered without providing the school with a written order from a licensed prescriber (Physician, Certified Nurse Practitioner, Physician s Assistant, or Dentist). The pharmacy label does not suffice as this written order. 2. Written Parent Permission - The school must also be supplied with written parent or guardian permission in order to have any medications given at school. ** If the order is for an Inhaler or Epinephrine Injector: parent must also complete and submit the corresponding forms: 3. Types of Medications Given at School - Only essential prescribed medications will be given at school. Pre-planning will permit most medications to be administered at home. Self-medication by students is not permitted. Exceptions will be made for any student with asthma or severe allergy, whose parent has requested that the student carry and administer his or her Inhaler or Epinephrine. 4. Prescription Medications For prescriptions medications required at school, please request that your pharmacist supply a separate, properly labeled, pharmacy medication bottle. 5. Over-the-Counter Medications - Medications must be in the manufacturer s original packaging, and labeled by the parent with the student s name. 6. Personnel Administering Medications - Medications may be administered by the nurse, or a supervising adult. 7. Transporting Medications - Students should not carry medications to or from school. A responsible adult should bring medications to the health room. 8. Yearly Medication Order - For those medications that extend from one school year to the next, a new order from the licensed prescriber and new parent permission must be provided for each school year. 9. Noncompliance with the Above Policy - Noncompliance will result in the medication not being given at school. *Parent and Licensed Prescriber must complete the reverse side of this form, and return it to the school nurse* Rev. 2014
Self Administration of Epinephrine by Injector Student Name Grade Type of Device: Dear Parent / Guardian: According to state guidelines, your child may carry and self-administer his / her Epinephrine Injector if it is determined that he / she is qualified. Please have your Health Care Provider complete the AUTHORIZATION FOR MEDICATION TO BE GIVEN AT SCHOOL form, then select one of the following options below, sign, and return both forms to the school nurse: Yes, I want my child to carry and self administer his or her Epinephrine* No, I want my child s Epinephrine Injector to be kept in the nurse s office. *In order for your child to be able to self-administer his or her Epinephrine at school, please read the following paragraph and sign your consent. I relieve the school district and its employees of any responsibility for the benefits or consequences of this medication that is physician, certified nurse practitioner, or physician assistant prescribed and parent / guardian authorized. I acknowledge that with Epinephrine Injectors that are carried by the student, the school bears no responsibility for ensuring that the medication is taken. I am aware that any improper use or sharing of medication will result in the immediate confiscation of the medication and loss of privilege to self-administer if the medication policy is violated. Parent Signature B. The following section is to be completed by the student: Date I agree to be solely responsible for my Epinephrine Injector and to follow the directions for its use as ordered by my health care provider, as well as the district s medication policy. I am aware that any improper use or sharing of medication will result in the immediate confiscation of the medication and loss of privilege to selfadminister, if the medication policy is violated. I agree to immediately notify the school nurse when I selfadminister my Epi-Pen. Signature of Student Date C. The following section is to be completed by the school nurse: OR: Check if Already on File To self medicate, the student must complete the following: (check if completed) 1. Respond to and visually recognize his or her name. 2. Identify his or her medication. 3. Demonstrate the proper technique for administration of the Epinephrine Injector. 4. If condition permits, sign his or her medication sheet showing the medication was taken. 5. Demonstrate a cooperative attitude in all aspects of self-administration. The above student has demonstrated the ability to self-administer his or her prescribed medication as indicated by the criteria listed above. Signature of Nurse Rev. 2014 Date
Authorization for Medication to be Given at School ** If the following is for an Inhaler or Epinephrine Injector: parent must also complete and submit the corresponding forms: Student s Name: Grade Date of Birth Parent s Home Phone: Emergency Phone: Health Care Provider s Name Phone: I request that the school comply with the medication order below. I agree to comply with the regulations listed on the reverse side of this form. I also hereby authorize and request that my child be assisted in taking the medication(s) below, by the persons listed on the reverse side of this form. I relieve the school district and its employees of any responsibility for the benefits or consequences of this medication that is physician, dentist, nurse practitioner or physician assistant prescribed and parent / guardian authorized. Parent / Guardian Signature Date B. The following section is to be completed and signed by the Physician, Dentist, Certified Nurse Practitioner, or Physician s Assistant prescribing the medication: Diagnosis for which medication is to be given: Name of Medication to be given: DIPHENHYDRAMINE HCL (BENADRYL) Dose: Frequency, Route, Time to be given: If ordered PRN describe indications: How soon can it be repeated? List Significant Side Effects: Length of time treatment is to take place:* *School Policy requires a new order for each school year. Inhalers: Student is qualified, able to carry, and self-administer the Inhaler: yes no Epinephrine: Student is qualified, able to carry, and self-administer the Epinephrine: yes no If Inhaler / Epinephrine is not effective in relieving symptoms, state further plan of action: Licensed Prescriber s Signature Date