INSTRUCTIONS: Each of the three sections must be completed by parent/guardian for student to receive an over-the-counter (OTC),
medication below. Check yes or no to indicate which of the approved list of over-the-counter medications may be
administered when indicated by student's symptoms. Parents will be notified when student receives an OTC medication.

I. STUDENT INFORMATION (To Be Completed By Parent/Guardian).
II. ACTION PLAN (To Be Completed By Parent/Guardian). Please complete all spaces.
Dosage and Time
Alert: Students with
Calcium Carbonate Administer according
Alert: Students will not be
Alert: Contains no aspirin
allergy to aspirin; may causestomach bleeding Sting Relief Pad™
*Manufacturer's label is maintained in the clinic for parents to review upon request
III. PARENTAL PERMISSION (To Be Completed By Parent/Guardian). Form is void if this section is incomplete.
I request the designated school personnel to assist my child in the administration of the above described medication/s. Igive permission for my child to take the medication indicated above by my checking the yes box according to thecondition/symptoms described while in school or while participating in school activities away from the school site. Iunderstand that: (1) there is no liability on the part of the school district, its personnel, or agents, including EscambiaCounty Health Department personnel, for civil damages as a result of the administration of this medication to my childwhen the person administering the medication acts as an ordinarily reasonably prudent person would have acted under thesame or similar circumstances; (2) these medications are stocked and maintained by school clinic with standing ordersprescribed by the Director of the Escambia County Health Department; (3) I will be notified of the medication and time thatthe OTC medication was administered to my child; (4) I will be contacted if my child's symptoms do not improve and s/he isunable to remain at school. I hereby authorize the exchange of medical information regarding my child's treatment planbetween the physician and school health personnel of the Escambia County Health Department and the Escambia SchoolDistrict. Furthermore, if my child is covered by Medicaid and receives services under an IEP, I consent for the schooldistrict to bill Medicaid for those services.
Students are not allowed to bring or carry any over-the-counter medications to school or school sponsored

Prescription Medication
1. An Authorization for Administration of Prescription Medication form (9400-HES-005A) must be filled out by the physician, and signed by the parent.
2. A separate authorization form must be filled out for EACH medication administered.
3. Changes in medication require a new authorization form signed by the physician and parent.
4. Medication must be in the original pharmacy-labeled container.
5. No more than a 30-day supply of medication may be accepted.
6. A responsible adult must deliver and pick-up the medications in the school clinic.
7. Notify clinic staff directly of any medication changes, including discontinued medications.
8. If your child is authorized to receive an early morning medication at school, do not give this dose at 9. Discontinued medication must be picked up by parent within one week of the stop date.
Unclaimed medication will be destroyed one week after the stop date.
10. During the last month of the current school year, bring only enough medication to be used by the last day of school. Unclaimed medication will be destroyed at the close of the last day of school.
Non-Prescription Medication
1. The ONLY non-prescription medications/over-the-counter medications that will be administered at school
are: a. Acetaminophen (Tylenol®) d. Ibuprofen (Advil®, Motrin®) b. Calcium Carbonate (Tums®) e. Sting Relief Pad (2% Lidocaine; external use only) c. Diphenhydramine (Benadryl®) Any medically required exception to the above non-prescription medication, requires an Authorization ofPrescription Medication form (9400-HES-005A) from the student's physician.
2. The Medical Director of Escambia County Health Department provides standing orders for these OTC medication to be administered with parental consent and according to the dosage and time on themanufacturer's label.
3. Authorization for Administration of Over-the-Counter Medication (OTC) form (9400-HES-005B) is available in the school clinic for parent to indicate which of these OTC medication/s can, or cannot, beadministered to the student each school year.
4. Over-the-counter medications as listed above are provided and maintained by the school health staff in the school's clinic in the original containers with the manufacturer's label.
5. Notify clinic staff directly of any medication changes, including withdrawal of parental consent.
6. Over-the-counter medications provided by the school will not be administered to pregnant or breast feeding students unless there is an Authorization of Prescription Medication form (9400-HES-005A) fromthe student's physician.
9400-HES-005 (Back) Revised: July 10, 2008


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