Medications

Medication Forms for medications at school & / or field trips
Please Read Completely!
All 2017-2018 medication forms must be dated after July 1, 2017 to be used for the 2017-18 school year!
OLD forms from previous years will NOT be accepted!

If you need any medication forms for the 2017-18 school year, please see DSA’s school nurse as she can direct you to the correct form to use for which medication.  The forms are also in the links below in case you need additional copies.

Please click on the attached forms below under each medication type.

1. For ALL medications given at school or on a school sponsored field trip except
    Epinephrine devises or Rescue Inhalers:
        – A
“Med Treatment Release Agreement” form must be completed by the parent
             and doctor
        – These forms are NOT for Epi-pens or Rescue Inhalers! 

      Forms:
          Student Med Treatment Release Agreement – Eng 17-18
          Student Med Treatment Release Agreement_Span 17-18

NOTE:  Tylenol and Ibuprofen are NO LONGER available by parent permission only or via a phone call!!  A “Med Treatment Release Agreement” form must be completed by a doctor and returned to the school nurse along with the ordered medication in an original bottle.

2. For Epinephrine devises like Epi-pens, Adrenaclick, Auvi-Q:
     – An “
Anaphylaxis Action Plan -Epinephrine Med Order” form must be completed by
          a parent and doctor.
     – If the doctor also wants to order
Benadyl or an Antihistamine as part of the  
        Anaphylaxis Plan then a “Med Treatment Release Agreement” form must also be
        completed for the Benadyl or Antihistamine.

     Note: There are additional forms & requirements below for a student to self-carry  
               their Epinephrine devise.

     Forms:
         Anaphylaxis Action Plan -Epinephrine Med Order
         Student Med Treatment Release Agreement – Eng 17-18
         Student Med Treatment Release Agreement_Span 17-18

3. For Rescue Inhalers at school use the following plan and order:
    
Form:
         Asthma Action Plan – Albuterol Med Order
     Note:  There are additional forms & requirements below for a student to self-carry
                their
Rescue Inhaler.

4. Students may self-carry Epinephrine / Benadryl or Rescue Inhalers in school if:
      – The doctor approves your child to self-carry on the
        “Anaphylaxis Action Plan -Epinephrine Med Order”
or
        “Asthma Action Plan – Albuterol Med Order” form.

      – A “Self-Carry Epi-pen Student Contract” or “Self-Carry Rescue Inhaler
           Student Contract” is completed by the parent, student, and school nurse.
     Forms:
        Contract to self-carry Epinephrine (& Benadryl if part of plan / order):
           Self-Carry Epi-pen Student Contract – English 17-18
           Self-Carry Epi-pen Student Contract – Spanish 17-18
        Contract to self-carry a Rescue Inhaler:
          
Self-Carry Rescue Inhaler Student Contract – English -17-18
           Self-Carry Rescue Inhaler Student Contract – Spanish 16-17

5. For Students with Diabetes
     – Please provide the school nurse at the beginning of the school year (preferably 
         before school starts) with your child’s Health Care Provider Orders, signed by
         both the doctor and parent.  
     – If your student is able to independently manage their diabetes,
         an “Independent Diabetes Management – Student Agreement” form
         must be completed by the student and parent and then the school nurse.
     Form:
         Independent Management of Diabetes – Student Agreement

Diabetes Care Plans for at school and other forms will be created by the school nurse after receiving both the Health Care Provider Orders and, if applicable, the “Independent Management of Diabetes – Student Agreement” forms.  Care Plans, etc. will be sent home after created, most likely with your student, for you to review, make corrections if necessary, sign and return to the school nurse.

You may also contact DSA’s school nurse for medication forms.

Updates will be posted as available.