Bedminster township school

Student Name: _________________________________ Date of birth: _______________ Grade: __________
Parent/Guardian Name: ______________________________________________________________________
Home Address: _____________________________________________________________________________
Parent/Guardian Phone: Home: _________________ Cell: _________________ Work: _________________
I request that my child be administered the following OTC medication(s) by the school nurse if needed throughout
the current school year as directed by my child’s medical provider below. I have read the reverse side of this form and
understand and assume the responsibilities as required. Medication authorization forms are effective for the school year in
which the order was written. New forms must be submitted each school year.
Parent/Guardian Signature: ______________________________________ Date: _______________________
This section for completion by Licensed Medical Provider:
Licensed Medical Provider Name: ______________________________________
Address: ______________________________________
Phone: ______________________________________
Provider’s Stamp: (Must be present to validate order)
The Following OTC Medications will be stocked in the school health office. Medications not listed must be
supplied by the parent/guardian and hand delivered to the school nurse.
Acetaminophen (liquid) (160 mg/5 ml), Acetaminophen/Children’s Tylenol melt-away tabs (80 mg/tab & 160 mg/tab),
Acetaminophen/Tylenol Regular strength (325 mg/tab), Ibuprofen liquid (100mg/5 ml) Ibuprofen/Motrin Junior Strength (chewable tabs)
(100 mg/tab) Ibuprofen/Advil (200 mg/tab), Diphenhydramine Hydrochloride/Benadryl liquid (12.5 mg/5 ml), and Diphenhydramine
HCL/Benadryl tablets (25 mg/tab)
MEDICATION: _________________________________________Route:______________ Dosage: ________________
Frequency: ___________________ Reason for use/signs & symptoms: _________________________________________
List side effects and/or contraindications: ________________________________________________________________
MEDICATION: __________________________________________Route: _____________ Dosage:_________________
Frequency: ___________________ Reason for use/signs & symptoms: ________________________________________
List side effects and/or contraindications: _________________________________________________________________
Provider’s Signature: _______________________________________ Date: ____________________

Medication(s) supplied by parent: _______________________________________ Expiration date(s): ___________________

The Board of Education disclaims any and all responsibility for the diagnosis and treatment of the illness of any pupil. At the same
time, the Board recognizes that a pupil’s attendance may be contingent upon the timely administration of medication duly
prescribed by a physician. The Board will permit the dispensation of medication in school only when the pupil’s health and
continuing attendance in school so require and when the medication is administered in accordance with this policy.

No medication will be administered to pupils in school except by the school physician, a certified or noncertified school nurse, a
substitute school nurse employed by the district, or the pupil’s parent(s) or legal guardian(s). Medication must be delivered to the
school nurse by the pupil’s parent(s) or legal guardian(s). The medication must be brought to the school nurse in the original
container labeled by the pharmacy or physician. Written orders signed by the pupil’s private physician or an advanced practice
nurse for the use of a pre-filled single dose auto-injector mechanism containing epinephrine, must be provided stating the name of
the medication, the purpose of its administration to the specific pupil for whom it is intended, its proper timing and dosage, its
possible side effects, and the time when its use will be discontinued. If written orders for use of a pre-filled single dose auto-
injector mechanism containing epinephrine are provided, the orders must say the pupil requires the administration of epinephrine
for anaphylaxis and does not have the capability for self-administration of the medication. These written orders must be reviewed
by the school physician prior to school approval for self-administration of any medication. The school physician may also issue
standing orders to the school nurse regarding the administration of medication. Medication no longer required must be promptly
removed by the parent(s) or legal guardian(s).
The school nurse shall have the primary responsibility for the administration of a pre-filled single dose auto-injector mechanism
containing epinephrine. However, the certified school nurse may designate, in consultation with the Board or the Superintendent,
another employee of the district trained by the certified school nurse in accord with the “Training Protocols for the Implementation
of Emergency Administration of Epinephrine” issued by the New Jersey Department of Education, to administer the pre-filled
single dose auto-injector mechanism containing epinephrine when the school nurse is not physically present at the scene. The
pupil’s parent(s) or legal guardian(s) must consent in writing to the designated person if applicable. In addition, the parent(s) or
legal guardian(s) must be informed that the school district has no liability as a result of any injury arising from the administration
of a pre-filled single dose auto-injector mechanism containing epinephrine, and the parent(s) or legal guardian(s) must sign a
statement that shall indemnify and hold the district and employees harmless against any claims arising from the administration of a
pre-filled single dose auto-injector mechanism containing epinephrine. The permission for the emergency administration of
epinephrine via a prefilled single dose auto-injector mechanism containing epinephrine to pupils for anaphylaxis is effective for the
school year it is granted and must be renewed for each subsequent school year.
A pupil is only permitted to self-administer medication for asthma or other potentially life-threatening illnesses.
The school shall have and maintain for the use of pupils at least one nebulizer in the office of the school nurse. Every pupil that is
authorized to use self-administered asthma medication pursuant to N.J.S.A.18A:40-l2.3 or a nebulizer must have an asthma
treatment plan prepared by the pupil’s physician which shall identify, at a minimum, asthma triggers, the treatment plan and other
such elements as required by the Department of Education.
All pupil medications shall be appropriately maintained and secured by the school nurse, except those medications to be
self-administered by pupils. In those instances the medication may be retained by the pupil with the prior knowledge of the
school nurse.
The school nurse may provide the Principal and other teaching staff members concerned with the pupil’s
educational progress with such information about the medication and its administration as may be in the pupil’s best educational
interests. The school nurse may report to the school physician any pupil who appears to be affected adversely by the
administration of medication and may recommend to the Principal the pupil’s exclusion pursuant to law.
The school nurse shall document each instance of the administration of medication to a pupil. Pupils self-administering medication
shall report each incident to a teacher, coach or other individual designated by the school district to be in charge of the pupil during
school activities. Such individuals shall report such incidents to the school nurse within twenty-four hours of the self-
administration of medication. The school nurse shall preserve records and documentation regarding the self-administration of
medication in the pupil’s health file.


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