MEDICATION AUTHORIZATION FORM

Notre Dame Parish School, Clarendon Hills, Illinois

____________________________      __________      _________________     ________

Student’s Name (Last, First, Middle)   Date of Birth     Grade/Room number        Date

Medications may be administered in school in accordance with the School Medication Procedures.  No medication may be administered in school unless both the student’s physician and parent/guardian have completed, signed, and returned the following to the School Principal or his/her designee:

X     Medical Authorization Form

X     Unsupervised Self-Administration Request Form (if the student is to carry and use    

        medication on his/her own during school hours or during school activities)

X     Medication in the original labeled container as dispensed (Prescription medication)

        or the manufacturer’s labeled container (Non-prescription medication).  The

        medication label shall contain the student’s name, name of the medication, direction

        for use and date.

Physician’s Order

____________________________     _______         ______________________ 

Medication/Health Care Treatment     Dosage           Time(s) to be administered                                          

___________________________                     ______________________

Intended effect of this medication                    Expected side effects, if any

Other medications the student is taking

May student self administer medication under supervision of school personnel who do not have medical training            Yes            No 

Administration Instructions:_______________________________________________

______________________________________________________________________

Discontinue   Re-evaluation    Follow-up   (Please circle)        ___________

                                                                                                     Date

_____________________________                                     ________________________

Physician’s / Prescriber’s Signature                                       Date Signed

_____________________________                                      ________________________

Physician’s / Prescriber’s Name                                            Emergency telephone number

Address:  _______________________________________________________________

Medication Authorization Approved this______day of _______________, 200__.
 

____________________________

School Representative’s Signature   (On behalf of Notre Dame School Clarendon Hills, Illinois)        

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Physician Request for Self-Administration of Medication

______________________________                                    ___________________

Name of Student                                                                     Date of Birth

To: Principal, Notre Dame Parish School, Clarendon Hills, Illinois:

The above named child has _________________________________________________

I am requesting that the above-named student be allowed to take the following medication during school hours or during school-related activities:

_______________________________________________________________________

Name of Medication           Type of Medication(tablet, liquid, capsule, inhaler, injectable)

_______________________________________________________________________

Dosage                                     Time(s) to be taken or administered

_______________________________________________________________________

Possible Side effects

I certify that this student has been instructed in the use and self-administration of this medication and is capable of self-administering the medication independently and without supervision (Circle one):     Yes      No

For ASTHMA and ALLERGY CONDITIONS ONLY:  I also request that this student be allowed to carry the above-described medication on their person during school hours and during school related activities in order to facilitate the self-administration of the medication as needed.   (Circle one)   Yes      No

_____________________________                                     ________________________

Physician’s Signature                                                             Date signed

_____________________________                                      ________________________

Physician’s Name                                                                  Emergency telephone number

Address:  _______________________________________________________________