Name of
student_______________________________ Date of Birth______________
Grade_______________
Parent/guardian
name________________________________________Home telephone___________________
Business telephone__________________________________________Cell Phone________________________
Food/drug Allergies__________________________________________________________________________
Diagnoses:_________________________________________________________________________________ (if not a violation of confidentiality)
Date Ordered___________________ Duration of
Order___________________Dosage____________________
Frequency___________ Route of Administration______________Expiration Date of
Medications __________
Quantity of Medication Received by School and
Date:______________________________________________
Specific Directions, e.g., times to be
given:______________________________________________________
_________________________________________________________________________________________
Possible Side Effects, Adverse
Reactions:_________________________________________________________
___________________________________________________________________________________________
Delegated to (if applicable): ________NA______ Back-up Plans (if delegatee unavailable):
___NA________
Plan for Field
Trips:________________________________Plan for Early Release Days___________________
Plans for teaching self administration, if
applicable:________________________________________________
_________________________________________________________________________________________
Other persons to be notified of medication
administration (with parental permission):_____________________
__________________________________________________________________________________________
Other medications being taken by the student (if not
in violation of confidentiality):_______________________
_________________________________________________________________________________________
Location where medication administration will occur: _____Health Room _____Other
(specify)____________
Plan for monitoring medication, if
needed:_______________________________________________________
School Nurse
Signature_____________________________________________Date______________________
Parent/Guardian
Signature___________________________________________Date______________________
Student's Signature, if appropriate________________________________________Date__________________