WESTERN RACINE COUNTY HEALTH DEPARTMENT

MEDICATION ADMINISTRATION REQUEST FORM

Student:  __________________________________________   Date of Birth:  ____________________

School:  __________________________________ School Year:  ___________   Grade:____________

MD’s Name:  _______________________    MD’s Phone:  _____________  MD’s Fax:  _____________

Phone number where Parent/Legal Guardian can be reached during school hours: _________________ 

PARENT/GUARDIAN AUTHORIZATION

I, the parent/guardian of the above named student, have read the school’s medication policy (on reverse side) and request

the medication listed below be administered to my child at school.  I understand that qualified, designated persons will

be administering the medication.  I will notify the school immediately if there is a change or cancellation of the

medication.  The School District has my permission to contact the prescriber in regard to the medication being prescribed.

If an over-the-counter medication is to be used for greater than 10 consecutive days, a physician’s signature

is required below or the medication will not be given.  Prescription medications will not be given for greater than two (2)

days unless this form is completed and signed by both the physician and parent.  It is impossible to arrange for this

medication to be taken at home, and therefore, it must be administered during the school hours:___Yes ___ No   

____________________          ___________________________________________________________

Date                                                   Signature (parent/guardian)

BRONCHIAL INHALERS, EPIPENS, and INSULIN.

Provisions for Self Administered Medications at School: 1) No documentation of self administered medication will be

kept by the school. 2) The school is not responsible for the safeguarding of self-administered medication.  I have read

and agree with these provisions for self-administration.  3) The School Nurse will attempt to meet with each student

annually who self-administer medications.

My child ___CAN ___CANNOT carry and self-administer the prescribed ___INHALER, ___EPIPEN  or __INSULIN.

____________________          ___________________________________________________________

Date                                                   Signature (parent/guardian)

Medication At School        Dosage                     Time(s)             Duration             Side Effects      Reason for Med.  

PHYSICIAN AUTHORIZATION

I authorize the administration of the medication listed directly above to the student named on this form.  I agree to be contacted by

the School District as needed regarding the medication.

PRN MEDICATIONS (If applicable)

Indications for use: _____________________________________________________________________

Plan following administration (if needed) ____________________________________________________

BRONCHIAL INHALERS, EPIPENS AND INSULIN (If applicable)

It is my professional opinion that the student named above ______CAN ______CANNOT   carry and self-

administer the prescribed ______INHALER, ______INSULIN, or ______EPIPEN.  He/she has been instructed in and

understands the purpose and appropriate use of the medication.   

_______________   ________________________________   __________________________________

          Date                           Signature of Physician                            Physician’s Name (Printed)

___________________________________________________________   ________________________

         Physician’s Address                       City             State/Zip Code                                       Phone

Wisconsin law permits a public school to administer medication prescribed by a physician to a child on behalf of the parent or legal guardian under certain limited circumstances with an appropriate written authorization.  If possible, all medications should be given outside of school hours.  Three times-a-day medications can be given before school, after school and at bedtime.  If necessary, medication can be given at school under the following conditions:

1. Medications must be in original, properly labeled containers.  The pharmacy can supply two (2) labeled bottles for this purpose.  Medications sent in baggies or unlabeled containers will not be given.

2. Over the counter medications given for greater than ten (10) consecutive days will not be given without a specific written request signed by at least one (1) parent/legal guardian and physician.  Prescription meds will not be given for greater than two (2) days without a completed and signed medication form (see front).

3. Most medications will be given by a non-medically licensed staff member designated by the principal and trained by the school nurse.

4. All medications must be kept in the school office in a locked cabinet except for inhalers, epipens, or insulin for which a physician has signed an authorization allowing the student to self carry.  Another inhaler or epipen may be kept in the office.  If a student allows another person to handle the self carry medications, the privilege will be revoked.  Students are not allowed to carry any other medications on their person or in their lockers.

5. Medication containers will be returned to the students when empty.  Parents are responsible for refilling and returning medication bottles to the school in a timely manner.

6. Herbal medications, dietary supplements and other nutritional aids not approved as a medication by the Federal Drug Administration (FDA) may not be administered at school without signed physician’s approval.

7. A current phone number where the parent/legal guardian can be reached during the school day for questions or medication concerns must be provided.  If a parent/guardian cannot be contacted when concerns arise, medications might not be given.

8. If a child fails to come to the office to take his/her medication for three (3) consecutive days, parents/guardians will be contacted.  Habitual failure to come to the office for medication will result in parent/guardian conference with school nurse and possible loss of medication administration privilege at school.  Students are responsible for coming to the office to take their mediation, as school staff will not track down or remind students.