RED ROCK CENTRAL
PUBLIC
SCHOOLS
District Office – Lamberton Elementary - Jeffers
PO Box 278, 100 6th Avenue East PO Box 68,
107 East Clark Street
Lamberton, MN 56152 Jeffers,
MN 56145
Phone 507-752-7361
Fax 507-752-6133 Phone
507-628-5521 Fax 507-628-5546
John
Brennan, Ph.D. Superintendent Bruce
Olson Principal Bryce
Pack Athletic
Director Linda
Riley Elementary-Lead
Teacher
MEDICATION
AUTHORIZATION FORM
Dear Parents,
School
District policy states that prescription medication may not be given to
students in the school setting unless a written request from the parent and
physician signature & verification in writing is received. Non-prescription medications require a
written request from the parent.
Please
complete and return this form along with the medication in an Original labeled container. The prescription medication label must
include the child’s name, physician, name and dosage of
the medication and route. Non-prescription
medications must be in an Original labeled bottle.
Each
medication requires a separate medication form.
If you have any questions, please contact the school office.
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Name of
Student:____________________________DOB:_____________________Grade:________________
List any Drug
Allergies:_______________________________________________________________________
Diagnosis:______________________________________Physician:_____________________________
Name of
Drug:________________________________________________
Dosage:_____________________________________
Time of Day or Frequency of
Use:_________________________________
Dates covered by this order:_______________ to
________________
Possible side
effects:____________________________________________________________
Physician
Signature:_______________________________________________
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I request that the above medication be given at school as
prescribed by our physician (if prescription) or by my permission (if
non-prescription)
Parent Signature:_________________________________Date:__________________________
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RN Contacted:
Signature:____________________________Date:_______________________
“Preparing Today’s Youth…For
Tomorrow’s Challenges”
STANDING MEDICAL ORDERS
For medication administration in the school setting
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1.
Prescription
Medication: The administration
of prescription FDA approved medications in the school setting will require the
written permission of the student’s parent & physician. The Licensed School Nurse shall be notified
to review the medication & then may delegate administration of the
medication to a school representative(s) who is adequately trained to carry out
administration of the medication. If the
Licensed School Nurse has any concern, the physician will be consulted prior to
administration of the medication.
2.
Non-Prescription
Medication: The administration of FDA approved
non-prescription medications such as Tylenol, aspirin, Ibuprofen, cough syrup,
nasal spray, antacids, etc. will require written permission from parent and
authorization by the Licensed School Nurse to be given in the school
setting. The nurse will review the
non-prescription medication and can delegate the medication to be given to the
student after the dosage is checked and determined to be safe to be
administered. If the nurse determines
any potential safety concerns, a physician will be contacted prior to
administration.
3.
Cough Drops: Cough or sore throat drops may be
administrated within the school setting with parental permission. Students in 5th grade of above
will be allowed to carry cough or sore throat drops with them and self-medicate
unless the student’s parent indicated not to allow this.
4.
Inhalers: Students with asthma or other respiratory
disorders may need to be allowed to carry an inhaler with them for use as a
rescue inhaler. This will be allowed
after the above requirements are fulfilled.
Staff will be notified of this special circumstance.
NOTE: Medication shall be kept in the office unless
the student’s parent has been contacted and other arrangements are made. Medications may be kept in a locked box in
the student’s classroom if that student’s teacher does the medication
administration. Red Rock Central and the
Licensed School Nurse will not be responsible to self-medicating students who
do not notify the school office of use of medications within the school
setting.