Groveport Madison Local School District Prescribed Medication Authorization

Student Information

Student name
	Date of birth
	
Student address
	
School
	Grade/Class
	Teacher
	School year
	
List any known drug allergies/reactions
	Height
	Weight

Prescriber Authorization

Name of medication
	Circumstance for use
	
Dosage
	Route
	Time/Interval
	
Date to begin medication
	Date to end medication

Circumstances for use

Special instructions

Treatment in the event of an adverse reaction

Epinephrine Autoinjector	❏ Not applicable
❏ Yes, as the prescriber I have determined that this student is capable of possessing and using this autoinjector appropriately and have provided the student with training in the proper use of the autoinjector.

Asthma Inhaler	❏ Not applicable
❏ Yes, if conditions are satisfied per ORC 3317.716, the student may possess and use the inhaler at school or at any activity event or program sponsored by or in which the student's school is a participant.

Procedures for school employees if the student is unable to administer the medication or if it does not produce the expected relief

Possible Severe Adverse Reaction(s) per ORC 3317.716 and 3313.718

a)To the student for whom it is prescribed (that should be reported to the prescriber)

b)To a student for whom it is not prescribed who receives a dose

Other medication instructions
Does medication require refrigeration?	❏ Yes ❏ No	Is the medication a controlled substance?	❏ Yes ❏ No

Prescriber signature
	Date
	Phone
	Fax

Prescriber name (print)

Reminder note for prescriber: ORC 3313.718 requires backup epinephrine autoinjector and best practice recommends backup asthma inhaler.

Parent/Guardian Authorization

þ I authorize an employee of the school board to administer the above medication. þI understand that additional parent/prescriber signed statements will be necessary if the dosage of medication is changed. þI also authorize the licensed healthcare professional to talk with the prescriber or pharmacist to clarify medication order.

þ Medication form must be received by the principal, his/her designee, and/or the school nurse. þI understand that the medication must be in the original container and be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration and the date of drug expiration when appropriate.
Parent/Guardian signature
	Date
	#1 contact phone
	#2 contact phone

Parent/Guardian Self-Carry Authorization

For Epinephrine Autoinjector: As the parent/guardian of this student, I authorize my child to possess and use an epinephrine autoinjector, as prescribed, at the school and any activity, event, or program sponsored by or in which the student’s school is a participant. I understand that a school employee will immediately request assistance from an emergency medical service provider if this medication is administered. I will provide a backup dose of the medication to the school principal or nurse as required by law.

For Asthma Inhaler: As the parent/guardian of this student, I authorize my child to possess and use an asthma inhaler as prescribed, at the school and any activity, event, or program sponsored by or in which the student’s school is a participant.
Parent/Guardian signature
	Date
	#1 contact phone
	#2 contact phone

HEA 7758 5/11 Adopted from the Ohio Department of Health 4/2012