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K-12 ADMINISTRATION OF MEDICATION

SYLVANIA SCHOOLS

4747 N. Holland-Sylvania Rd
Sylvania, Ohio 43560	Valid for School Year:  	

A completed form must be on file for any student requiring medication during school hours.
Student’s Name: 	D.O.B.:	School: 	_ Parent’s Name: 			Phone:			 Address:  					

The parent signing below:
1.	Requests and gives permission to the principal or designee to administer the medication described below to their child.
2.	Will deliver this medication to the school. NOTE: Medication is NOT to be brought to school by the student.
3.	Will notify the school if the medication, dosage, or procedure is changed or if it is to be eliminated, and provide a physician order reflecting the change.
4.	All medication dispensed at school must have a prescription label with medication, dosage, and times taken.
5.	Asthma inhaler, Auvi-Qs and EpiPens may be self-administered with a physician order; all other medication will be under the control and supervision of school personnel.
6.	Over the counter medications will require a physician signature and must also be under control and supervision of school personnel

HB 121 Provides schools/school employees with protection from liability resulting from the use/misuse of inhalers by students.

Parent/Guardian Signature	Date  	
To be completed by the student’s Primary/Managing Physician

Name of medication 					_Purpose of medication 			 Duration of medical treatment 						 Dosage 	Frequency 	Method of administration 		 Anticipated reaction(s) of student to medication 					 Reactions which should be reported to physician 					 Special instructions (storage/sterile requirements) 					 Date 		Physician’s Signature 				 Physician’s Name 				Address 	_ Please return to student’s school after completion either via parent, mail, or fax.