|PDF Download||SCHOOL MEDICATION AUTHORIZATION FORM|
School Year: _______________________________________________
Student’s Name:___________________________________ Birth Date:_______________________________
School:_______________________________ Grade:________ Teacher:_______________________________
TO BE COMPLETED BY HEALTHCARE PROVIDER:
This order can only be signed by Physician (MD, DO), Dentist, Nurse Practitioner (NP, FNP, PNP, APRN/PP), or Certified Physician’s Assistant. Utah Law (53a-11-501) requires that medication administered during school hours must be medically necessary.
|***||ONLY ONE MEDICATION PER FORM||***|
MEDICATION SELF-ADMINISTRATION AUTHORIZATION
[ ] Auto-Injectable Epinephrine [ ] Inhaler [ ] Insulin
Name of Healthcare Provider: __________________________________________________ Phone: _________________________
- Parent must furnish the school with a completed School Medication Authorization Form prior to any medications being administered by school personnel.
- The medication must be delivered to the school by the parent in the original container, labeled with the child’s name, medication, time, dosage, and healthcare provider’s name.
- All medication must be delivered to the school by an adult and picked up by an adult within two (2) weeks of last dose given.
- If there is a change in the medication or medication dosage, a new School Medication Authorization Form must be completed before school personnel can administer the new medication or new medication dose.
I UNDERSTAND THAT BY SIGNING THIS FORM:
- I am giving permission to the school personnel to contact the healthcare provider regarding this medication.
- I am giving permission for this medication to be administered by someone other than a licensed nurse who has been appointed by the school administrator.
- School personnel cannot give the following:
- The 1st dose of a new medication OR the 1st dose of a dosage change of any medication.
Parent Signature: _____________________________________________________________ Date:________________________
Emergency Phone Number(s): ________________________________________________________________________________
School Nurse Signature: _______________________________________________________ Date:________________________