Ohio Department of Health
Authorization for Student Possession and Use of an Asthma  Inhaler

In accordance with ORC 3313.716/3313.14

A completed form must be provided to the  school principal and/or nurse  before the  student may  possess and use  an asthma inhaler  in school to alleviate asthmatic symptoms, or before exercise to prevent the  onset of asthmatic symptoms.
Student name

Student address

This section must be completed and signed by the  student’s parent  or guardian.

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	
Parent /Guardian  name	Parent /Guardian  emergency telephone number
(	)	

This section must be completed and signed by the  student’s physician.
Name  and dosage of medication

Date  medication administration begins 	Date  medication administration ends (if known)

Procedures for school  employees if the  medication does not produce the  expected relief

Possible severe adverse reactions:
To the  student for which  it is prescribed (that should  be reported to the  physician) To a student for which  it is not  prescribed who  receives a dose

Special  instructions

Physician signature	Date	
Physician  name	Physician  emergency telephone number
(	)	

Adapted from the  Ohio Association of School  Nurses

HEA 4223   3/07