Student Information

Medication Administration Record (MAR) General Medication Form
(Including Asthma Inhaler and Epinephrine Autoinjector Use)

Student name	Date of birth	
Student address	
School	Grade/Class	Teacher	School year	
List any known drug allergies/reactions	Height	Weight	

Prescriber Authorization

Name of medication	Circumstance  for use	
Dosage	Route	Time/Interval	
Date to begin medication	Date to end medication	
Circumstances  for use	
Special instructions	
Treatment in the event of an adverse reaction	
Epinephrine Autoinjector 	❏  Not applicable 
❏  Yes, as the prescriber  I have determined that this student is capable of possessing and using this autoinjector appropriately and have provided the student
with training in the proper use of the autoinjector.	
Asthma Inhaler	❏  Not applicable 
❏ Yes, if conditions  are satisfied per ORC 3317.716, the student may possess and use the inhaler at school  or at any activity event or program  sponsored  by or in which the
student's school is a participant.	
Procedures for school employees if the student is unable to administer the medication or if it does not produce the expected relief	
Possible Severe Adverse Reaction(s) per ORC 3317.716 and 3313.718
a) To the student for whom it is prescribed (that should be reported to the prescriber)

b) To a student for whom it is not prescribed who receives a dose	
Other medication instructions
Does medication require refrigeration?	❏ Yes     ❏ No         Is the medication a controlled substance?   ❏ Yes    ❏ No 	
Prescriber signature	Date	Phone	Fax	
Prescriber name (print)

Reminder note for prescriber: ORC 3313.718 requires backup epinephrine autoinjector and best practice recommends backup asthma inhaler.	

Parent/Guardian Authorization

þ	I authorize an employee of the school board to administer the above medication. þ I understand that additional parent/prescriber  signed statements will be necessary  if the dosage of medication is changed. þ I also authorize the licensed healthcare professional to talk with the prescriber or pharmacist to clarify medication order.

þ	Medication form must be received by the principal, his/her designee, and/or the school nurse. þ I understand that the medication must be in the original container and be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration  and the date of drug expiration when appropriate.	
Parent/Guardian signature	Date	#1 contact phone	#2 contact phone	

Parent/Guardian Self-Carry Authorization

q	For Epinephrine Autoinjector: As the parent/guardian of this student, I authorize my child to possess and use an epinephrine autoinjector, as prescribed, at the school and any activity, event, or program sponsored by or in which the student’s school is a participant. I understand that a school employee will immediately request assistance from an emergency medical service provider if this medication is administered. I will provide a backup dose of the medication to the school principal or nurse as required by law.

q	For Asthma Inhaler: As the parent/guardian of this student, I authorize my child to possess and use an asthma inhaler as prescribed, at the school and any activity, event, or program sponsored by or in which the student’s school is a participant.	
Parent/Guardian signature	Date	#1 contact phone	#2 contact phone	
HEA 7758 5/11	❏ File per district policy