BYRAM TOWNSHIP SCHOOLS
REQUEST FOR SELF-ADMINISTRATION OF MEDICATION
Student’s
Name____________________________D.O.B.__________________School__________Date__________
Parent/Guardian
Name_____________________________________________Tel.# Work_____________________
Home_____________________
Physician’s
Authorization: (please print)
I am
recommending that the above-named student be allowed to self-administer the
following medication:
Identification
of Chronic Medical Problem:____________________________________________________________
Name
and purpose of
medication:____________________________________________________________________
Prescribed
dosage to be
taken:_______________________________________________________________________
Length
of time medication must be
taken:______________________________________________________________
Possible
side effects and/or special precautions to be
taken:________________________________________________
________________________________________________________________________________________________
Conditions
under which self-administration will take place:
1. Independently. Child must have had training and be
proficient in self-administering medication.
Trainer’s
name_____________________________________________Date of
Training_________________
2. Medication will be in the possession of student. As part of the above training, the student
has been instructed regarding the responsibility for caring for his/her
medication.
____________________________________ ________________________________________
Physician’s Name (Print)
Physician’s Signature
____________________________________ ________________________________________
Telephone Number
Date
Parental Authorization: I give my permission for my child to self-administer the medication
described above. I will
notify the school nurse if
this medication is no longer required or self-medication is no longer directed
by the physician.
I understand and I acknowledge that the Byram
Township School district and it’s employees or agents shall
incur no liability as a
result of any injury arising from the self-administration of medication by my
child.
I indemnify and hold harmless the Byram Township
School district and its employees or agents against any
claims arising out of the
self-administration of medication by my child.
I understand also, that the permission of
self-administration of medication by my child is effective only for
the school year in which it
was granted and that renewal of this permission will require application during
each of the
subsequent school years when
the self-medication is needed.
I understand that the privilege of self-medication
may be withheld if the student fails to comply with this
policy and the conditions of
this agreement.
________________________________
Parent
Signature
TO BE COMPLETED BY BYRAM TOWNSHIP SCHOOLS’ MEDICAL EXAMINER
I
have reviewed this request for self-administration of emergent medication and
recommend that it
1.
be approved
2. not be approved
If
number 2 is checked, please state reason:
____________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
____________________________________ __________________
Signature of Medical Director Date
If
approved by Medical Director -
____________________________________ ___________________
Chief School Administrator’s Signature Date
If
approved by Chief School Administrator -
____________________________________ __________________
Principal’s
Signature Date
____________________________________ __________________
Nurse’s
Signature Date
Classroom
teacher/teachers or other school personnel has/have been notified on
_____________________________ _______________________________________________
Date Nurse’s
Signature
*Copies
of completed form must be forwarded to the Chief School Administrator,
Principal and Student Health File.