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Medicationform

Authorization for Medication
Return form to school with Parent and Health Care Provider signatures
Student Name ______________________________________________________ Date of Birth
Parent’s Name
Phone (home)
Emergency Contact Name
Phone (home)________________Cell___________________
When the district has received written orders from the student's physician and written permission from the parent/guardian, the school
nurse or other designated personnel under supervision of the EUSD school nurse shall assist the student in taking the medication. All
medication must be brought to school in an original container and appropriately labeled by the pharmacist. Parents/guardians may
request that the pharmacist dispense two bottles of medication, one for home and one for school. Written permission must also be
provided for students to carry and self-administer prescribed medication. (CA Education Code 49423; EUSD Board Policy 5141.21).
To Be Completed By Health Care Provider
Name of Medication or
Refrigerate?
Treatment
Administer?
 Yes, supervised  Yes, unsupervised  Yes, supervised  Yes, unsupervised  Yes, supervised  Yes, unsupervised  Yes, supervised  Yes, unsupervised
Diagnosis/Significant Findings:
Allergies (Medication/Other substances)
This Box Only Needs To Be Completed If Student Has ASTHMA

To provide assistance to a student experiencing asthma symptoms:

If you see or hear the following symptoms, follow Health Care Provider Orders
 Noisy breathing  Coughing  Shortness of breath Complaint of chest tightness Difficulty breathing  Other ___________ ealth Care Provider Orders
1. Stay with student, speak softly, and stay calm 2.
Keep student sitting upright and encourage slow deep breathing 3. Give quick relief medication Albuterol Inhaler 2 puffs with spacer
Location of medication:
Have helper call guardian and school nurse If symptoms do not improve, repeat in 5-10 minutes. 6. Call 911 if you see any of the following: Student having trouble walking or talking, stooped body posture, skin pulling in
around collarbone and ribs with breathing, continuous coughing, or lips or fingernails turning gray, blue, or purple
May give 3-4 puffs albuterol every 20 minutes (3 times maximum) until medical help arrives.
Does student need medicine before PE or sports?  No  Yes Albuterol Inhaler- 2 puffs with spacer, 15-20 minutes before exercise; Other quick relief medication __________________________
Health Care Provider Signature:

Address:

Phone: _______________

To be completed by parent or guardian:
I authorize the school nurse and/or other trained school personnel to assist my child in taking his/her medications and treatments, and I authorize the
nurse to consult with the Health Care Provider about my child’s medical needs as necessary while my child is at school.
Parent Signature:

Source: http://www.californiabreathing.org/phocadownload/QuickTake/asthma_medication_school_authorization_form.pdf

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