MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C6906E.0A9C1000" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C6906E.0A9C1000 Content-Location: file:///C:/3A4BB24E/Authorization.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"

        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      H144

 

MUKILTEO SCHOOL DISTRICT

Health Services

MEDIC= ATION AUTHORIZATION (Prescription and Non-Prescription)

 <= /o:p>

Student  =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =         School        &= nbsp;           &nbs= p;            &= nbsp;   

 

Teacher  =             &nb= sp;            =             &nb= sp;        Grade        &= nbsp;           &nbs= p;            &= nbsp;     DOB        &= nbsp;           &nbs= p;            &= nbsp;     

 

Health care provider complete this section MUST BE TYPED OR PRINTED

 

Diagnosis or reason for medication            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =         

 

Name of medication  &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            = Dose        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;  

 

Please complete: Daily &nbs= p;         As Needed            Time/Directions         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           

 

If medication is to be given as needed, describe indications        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;      

 

Possible side effects  = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;                   &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           

 

Is child allowed to possess and self-administer above named asthma = or anaphylactic medication?

      = ;          <= span style=3D'font-size:10.0pt'>Yes.  I have trained this student in the purpose and appropriate method and frequen= cy of use as per RCW 28A.210.

      = ;          <= span style=3D'font-size:10.0pt'>No

 

This medication cannot be scheduled except during school hours.=

 

Health Care Provider Signa= ture        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;                  &= nbsp;       Title        &= nbsp;           &nbs= p;           &= nbsp;       Date        &= nbsp;           &nbs= p;  

 

 Name        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                  &= nbsp;       Address        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

 

City, Zip    = ;            &n= bsp;            = ;            &n= bsp;            = ;           Ph= one        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;       Fax        &= nbsp;           &nbs= p;            &= nbsp;       

      = ;            &n= bsp;            = ;         =              This box must be typed or printed to be valid per state law

 

Parent/Guardian complete this section

  Under normal circumstances, medication should be administered before and/or after school hours.  If a student must rece= ive medication at school, the parent/guardian must submit this written request = and authorization.  Written direct= ions from the licensed health care provider prescribing within the scope of his/= her prescriptive authority must be included.&n= bsp; The medication must be provided in the original, labeled container.<= span style=3D'mso-spacerun:yes'>  If for any reason the District que= stions the identification/instructions of the medicine presented, the District has= the authority to withhold administration of the medicine until clarification of= the identification/instructions.  = The District will substantially comply with the schedule of administration indicated by the licensed health care provider.  Parent/guardian shall agree in wri= ting that due to school schedules and other factors, administration of dosages m= ay be interrupted.

  Having read the abov= e, I hereby request that medication be stored and administered at school.   Further, I will hold the Dis= trict and school personnel harmless from any liabilities that might result from administering the medication, lack of administering the medication or self-administration of asthma or anaphylactic medication.=

 

Parent/Guardian Signature &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;        Date        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          =

Home Phone   &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;   Cell Phone      = ;            &n= bsp;            = ;            &n= bsp;            = ;     Work        &= nbsp;           &nbs= p;            &= nbsp;   

 

I request that my child be allowed to carry and self-administer his= /her prescribed asthma or anaphylactic medicine provided that the conditions of = RCW 28A.210.370 are met (see page 2).  Parent Signature   = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;

 

To be completed by school nurse

Student responsibilities for carrying and self-administering asthma and/or anaphylactic medication:

 

YES         = NO  (date)

&n= bsp;            = ;            &n= bsp;      Stud= ent is consistently able to:

___     &n= bsp;   ___         = Identify the correct medication

___     &n= bsp;   ___         = Identify the purpose of the medication

___     &n= bsp;   ___         = Identify specific symptoms and need for medication administration<= /p>

___     &n= bsp;   ___         = State the correct dosage

___     &n= bsp;   ___         = State side effects/adverse reactions to this medication

___     &n= bsp;   ___         = Describe what will happen if medication is not taken

___     &n= bsp;   ___         = Demonstrate the correct method of administration

___     &n= bsp;   ___         = Identify safety issues (i.e., no sharing of medication, safe storage, consistent placement)

___     &n= bsp;   ___         = Demonstrate knowledge of how to access assistance from school staff if needed in an emergency

 

School Nurse Signature &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;            Date        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          =

 

 

<= span style=3D'mso-list:Ignore'>1.&n= bsp;     WHEN POSSI= BLE, THE PARENTS AND PHYSICIAN ARE URGED TO WORK OUT A SCHEDULE OF MEDICATION OUTSIDE OF SCHOOL HOURS.

 

<= span style=3D'mso-list:Ignore'>2.&n= bsp;     A school nurse often serves more than one school an= d is not available every day to administer medications.  Other school personnel have been t= rained to provide such required medication when necessary.

 

<= span style=3D'mso-list:Ignore'>3.&n= bsp;     All medication requires a signed Medication Authorization form (H144) from the parents and licensed health professional prescribing within the scope of his/her prescriptive authority for school personnel to administer the medication. Each medicine prescribed for administration at school requires a separate Medication Authorization.=

 

<= span style=3D'mso-list:Ignore'>4.&n= bsp;     Medication orders must be renewed annually or when a change in medication and/or dosage is made. A new medication form must be completed at the beginning of the school year.

 

<= span style=3D'mso-list:Ignore'>5.&n= bsp;     Medication must be brought in the original, properly labeled container.

 

<= span style=3D'mso-list:Ignore'>6.&n= bsp;     Students requiring epinephrine injections for life-threatening conditions (i.e., severe allergic reaction to bee sting an= d/or food) shall provide the school with EpiPen injectable medication.

 

<= span style=3D'mso-list:Ignore'>7.&n= bsp;     All medication will be kept in the school office un= less otherwise directed by the licensed health professional and the principal.

 

<= span style=3D'mso-list:Ignore'>8.&n= bsp;     RCW 28A210= .370 Conditions required for self-administration of medication to treat asthma or anaphylaxis:

·        Medical provider prescribes the medication f= or use during school hours and instructs the student in the correct and responsible use of the medication.

·        The student has demonstrated to the medical provider (or designee) and to the school nurse the skill level necessary to= use the medication and any device that is necessary to self-administer the medication as prescribed.

·        The medical provider formulates a written treatment plan for managing asthma or anaphylaxis episodes of the student a= nd for medication use by the student during school hours.

·      =    The student’s parent/guardian has completed and submitted to school any written documentation required by the school.

 

 

 rev 5/06 ap

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