AUTHORIZATION-ASTHMA OR AIRWAY CONSTRICTING MEDICATION
February 26, 2006
Code 504.4
Exhibit D
Page 1 of 2
AUTHORIZATION-ASTHMA OR AIRWAY CONSTRICTING MEDICATION
SELF-ADMINISTRATION CONSENT FORM
I am the parent/guardian/custodian of ______________________________________________
(student's full legal name), date of birth _____________________________in the_________ Building in the Ogden Community School District.
In order for a student to self-administer medication for asthma or any airway constricting disease:
*Parent/guardian must provide a signed, dated authorization for student medication self-administration.
*Physician (person licensed under chapter 148, 150, or 150A), physician's assistant, advanced registered nurse practitioner, or other person licensed or registered to distribute or dispense a prescription drug or device in the course of professional practice in Iowa in accordance with section 147.107, or a person licensed by another state in a health field in which, under Iowa law, licensees in this state may legally prescribe drugs), must provide written authorization containing:
*purpose of the medication,
*prescribed dosage,
*times or;
*special circumstances under which the medication is to be administered.
*The medication must be in the original, labeled container as dispensed or the manufacture's labeled container containing the student's name, name of the medication, directions for use, and date.
*Authorization must be renewed annually. If any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.
Provided the above requirements are fulfilled, a student with asthma or other airway constricting disease may possess and use the student's medication while in school, at school-sponsored activities, and before and after normal school activities, such as while in before-school or after-school care on school property. If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed.
Pursuant to state law, the school district and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication by the student as established by Iowa Code �280.16.
Code 504.4
Exhibit D
Page 2 of 2
AUTHORIZATION-ASTHMA OR AIRWAY CONSTRICTING MEDICATION
SELF-ADMINISTRATION CONSENT FORM
_______________ _________________ _______________ _______________
Medication Dosage Route Time
________________________________________________________________________________
Purpose of Medication & Administration Instructions
_____________________________________ ____________________________________
Special Circumstances Discontinue or Re-Evaluate Date (mark which)
_____________________________________ _________________________________
Prescriber's Signature Date
______________________________________
Printed Name
________________________________________ _________________________________
Prescriber's Address Emergency Phone
*I request the above named student possess and self-administer asthma or other airway constricting disease medication(s) at school and in school activities according to the authorization and instructions.
*I understand the Ogden Community School District and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or for supervising, monitoring, or interfering with a student's self-administration of medication.
*I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.
*I agree to timely provide safe delivery of medication and equipment to and from school and to timely pick up remaining medication and equipment.
*I agree to provide the school with back-up medication approved in this form.
_______________________________________ _____________________________
Parent/Guardian Signature Date
(agree to above statement)
________________________________________
________________________________________ _______________________________
Parent/Guardian Address Home Phone
________________________________
Business Phone
_______________________________________________________
Email Address
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Self-Administration Authorization Additional Information
Form Adopted: March 21, 2005
AUTHORIZATION-ASTHMA OR AIRWAY CONSTRICTING MEDICATION
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