Student Medication Request Form
Authorization/ Self-administration of asthma/ anaphylaxis medication
The abridged guideline, revised in June 2016.
When an underlying health problem necessitates the administration of medication during the school day or at a school-related activity, authorized school personnel may administer medication to students. The administration of medication by a district employee to a student must be conditioned on the District’s receipt of a written request to administer the medication from the parent, legal guardian or other person having legal control of the student. Below outlines important information regarding medication administration. For additional information, please contact your campus school nurse or clinic aide.Parent/Guardian Requests for Administration of Medication and Receipt of Medication
- All medication must be checked into the clinic. Students may not carry medication at school or during off-campus activities. Exceptions may apply to the student's self-administration of prescription medication for the management of asthma, anaphylaxis, and diabetes if administered per district policy and procedure. (See Self-Administration of Medication below).
- If medication is delivered to the clinic from someone other than the parent/guardian or student, e.g., grandmother, friend, etc., a parent written request for medication administration must be received.
- A written request must be provided for each medication checked in to the campus clinic. The request may be submitted as a handwritten request or per the District’s Student Medication Request Form. The request must include:
- Student’s name
- Name of the medication
- Directions for administering, including the time the medication is to be given and dosage
- Date of written request and number of days the medication is to be given
- Reasons for medication
- Possible side effects
- Student medication allergies (if any)
- Parent/Guardian signature
- Clinic personnel should assess whether the need for medication is necessary at school. Requests deemed essential include:
- Prescription medication ordered to be administered greater than three (3) times a day
- Emergency medication
- As-needed medicines (no more than 15 doses stored at school) occasionally needed for students for relief of commonly occurring symptoms (e.g., headache) allowing a student to remain at school.
- Medication must be received in the original container, and the label must include the following:
- Name and address of the pharmacy (prescription medication)
- Name of the student (prescription)
- Name of the prescribing healthcare provider (prescription)
- The date the prescription is dispensed (prescription)
- Instructions for use (prescription and nonprescription medication)
- The expiration date of the medication (prescription and nonprescription medication)
- Before requesting medication administration at school, the initial dose must be administered at home, and the parent must report the effects of the medicine to school personnel.
- Medication checked into the school clinic must be picked up by the end of the last day of school. All remaining medication will be discarded per district guidelines.
- Only FDA approved medication, prescription or nonprescription, will be accepted.
- Products containing aspirin will not be administered without a prescriber's order.
- No school-supplied medication will be administered upon student or parent request. All medication must originate from home.
- Sample medication provided by a healthcare provider can be administered when the medication is accompanied by a written order from the student’s healthcare provider explaining the dosage and frequency AND written permission from the student’s parent or legal guardian.
- Herbal substances or dietary supplements (including essential oils) provided by the parent and only if required by the individualized education program or Section 504 plan of a student with disabilities. The parent shall provide a written request from the prescribing physician or another health-care professional with prescriptive authority who is licensed to practice in Texas. These substances shall be administered only by employees who have been authorized to do so by the superintendent or principal’s designee. The request shall include:
- Identification of the condition for which the product is being used;
- Verification that the product and requested dosage are safe for the student; and
- Reasonable information about therapeutic and untoward effects and interactions.
Administration of Medication
- Administration of prescription medication must follow dosage instructions contained in the prescription or written directions from the healthcare provider.
- Nonprescription medication must be given according to the directions provided on the medication's label. A healthcare provider's order must accompany requests to modify instructions.
- If tablets are to be administered in portions and a Registered or Vocational Nurse is not available, parents must cut tablets.
- Although every effort will be made to ensure the administration of medication on a timely basis, CISD personnel are not responsible for any missed doses, including dosages not given because of absences or student refusal.
Medication Administration in Special Circumstances:
Self-Administration of Medication:
- Students are entitled to possess and self-administer a prescription inhaler or epinephrine auto injector while on school property or at school-related activities provided the following:
Field Trips and School Related Events Occurring Before/After School or on Weekends
- The medication is prescribed for the student
- Self-administration is done in compliance with the healthcare provider’s written instructions or prescription
- A Permit for the Self-Administration of Asthma or Anaphylaxis Medication form is completed by both parent and healthcare provider and submitted to be kept on file in the school clinic for one year
Medication Administration for Overnight Field Trips
- All CISD medication guidelines must be followed when medication is to be administered during field trips or school related events occurring off campus or outside the normal school day.
- No medication will be sent automatically from the clinic for field trips or school related events; all requests must be prearranged.
- Parent/guardian must notify clinic personnel each time a student is scheduled to attend a field trip or is involved in a school related event occurring before/after school or on weekends when medication administration is necessary.
- Only scheduled prescription medication and emergency medication will be considered for preparation from the clinic for special events. For all other requests, the parent shall provide a written request and statement from their healthcare professional with prescriptive authority who is licensed to practice in Texas. The statement shall include the reason the medication should be available for the student during the timeframe a field trip or school related event is scheduled.
- Based on the length of the trip, the parent shall provide the required amount of medication in a properly labeled, original container with the required written parent request or Student Medication Request.
- No medication will be sent automatically from the clinic for overnight field trips; all requests must be prearranged