507.02 ADMINISTRATION OF MEDICATION TO STUDENTS

The board is committed to the inclusion of all students in the education program and recognizes that some students may need prescription and nonprescription medication to participate in their educational program.

Medication shall be administered when the student's parent or guardian (hereafter "parent") provides a signed and dated written statement requesting medication administration and the medication is in the original, labeled container, either as dispensed or in the manufacturer's container.  Administration of medication may also occur consistent with board policy 507.4R1 - Stock Epinephrine Auto-Injector Supply.

When administration of the medication requires ongoing professional health judgment, an individual health plan shall be developed by the licensed health personnel working under the auspice of the school with collaboration the parent or guardian, individual’s health care provider or education pursuant to 050.14.2(256). Students who have demonstrated competence in administering their own medications may self-administer their medication. A written statement by the student's parent shall be on file requesting co-administration of medication, when competence has been demonstrated.    By law, students with asthma, or other airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon approval of their parents and prescribing licensed health care professional physician regardless of competency.

Persons administering medication shall include authorized practitioners, such as the licensed registered nurses, physician, and persons to whom authorized practitioners have delegated the administration of medication (who have successfully completed a medication administration course conducted by a registered nurse or pharmacist that is provided by the department of education).  The medication administration course is completed every five years with an annual procedural skills check completed with a registered nurse or a pharmacist.  A record of course completion shall be maintained by the school.

A written medication administration record shall be on file including:

  • date;
  • student’s name;
  • prescriber or person authorizing administration;
  • medication;
  • medication dosage;
  • administration time;
  • administration method;
  • signature and title of the person administering medication; and
  • any unusual circumstances, actions, or omissions.

Medication shall be stored in a secured area unless an alternate provision is documented.  The development of  emergency protocols for medication-related  reactions is required.   Medication information shall be confidential information as provided by law.

Disposal of unused, discontinued/recalled or expired abandoned medication shall be in compliance with federal and state law.  Prior to disposal school personnel shall make a reasonable attempt to return medication by providing written notification that expired, discontinued, or unused medications need to be picked up.  If medication is not picked up by the date specified disposal shall be in accordance with the disposal procedures for the specific category of medication.

NOTE: School districts may stock over-the-counter, nonprescription medications that are not for life-threatening incidents. The policy for medication administration covers prescription and nonprescription medication. 

Legal Reference:        

     Disposing on Behalf of Ultimate Users, 79 Fed. Reg. 53520, 53546 (Sept. 9, 2014)     

     Iowa Code §§124.101(1), 147.107, 152.1, 155A.4(2); 280.16,  280.23.                                                                                                                 

     281 IAC §14.1,2

 

Cross Reference:       

     507.4R1  Stock Epinephrine Auto-Injector Supply

     603.3 Special Education

     607.2  Student Health Services

     607.2-R1  Student Health Services - Regulation  

 

Approved:  2/10/1997               Reviewed:  08/14/2023         Revised:  08/14/2023

 

507.02E1 TIPTON COMMUNITY SCHOOL DISTRICT AUTHORIZATION-ASTHMA, AIRWAY CONSTRICTING, OR RESPIRATORY DISTRESS MEDICATION SELF-ADMINISTRATION CONSENT FORM

Student's Full Name:__________________________________________________                   Date of Birth:_________________________               

School:____________________________________________________________                     Date:  _____________________

 

In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or student at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency.  The following must occur for a student to self-administer asthma medication, bronchodilator canisters or pacers, other airway constrict disease medication or to self-administer an epinephrine auto-injector:

  • Parent/guardian provides signed, dated authorization for student medication self-administration.

  • Parent/guardian provides a written statement from the student’s licensed health care professional (A person licensed under chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under chapter 152 or 152E and registered with the board of nursing, or a physician assistant licensed to practice under the supervision of a physician as authorized in Chapters 147 or 148C) containing the following:,

  • Name and purpose of the medication,

  • prescribed dosage, and

  • times or special circumstances under which the prescribed medication is to be administered.

  • The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.

  • Authorization shall be renewed annually.  In addition 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, the school shall permit the self administration of the prescribed medication by a student while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before- school or after-school care on school-operated 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, after notification is provided to the student’s parent.

Pursuant to state law, the school district or/and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district or nonpublic school is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine auto-injector by the student as provided by law.

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION-ASTHMA, AIRWAY CONSTRICTING, OR RESPIRATORY

DISTRESS MEDICATION SELF-ADMINISTRATION CONSENT FORM

______________         __________     _____________________    _________                                                     

Medication                   Dosage             Route                                     Time 

 

______________________________________________________________________                                           

Purpose of Medication & Administration /Instructions

 

__________________________________    _________/__________/___________                                                   

Special Circumstances                                   Discontinue/Re-Evaluate/ Follow-up date

 

________________________________       _____/_____/_____                                                                           

Prescriber’s Signature                                    Date

 

_________________________________     ______________________________                                               

Prescriber’s Address                                     Emergency Phone

  • I request the above named student possess and self-administer asthma medication, bronchodilators canisters or spacer or other airway constricting disease medication(s) and/or an epinephrine auto injector at school and in school activities according to the authorization and instructions.

  • I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or an epinephrine auto-injector or for supervising, monitoring, or interfering with a student's self-administration of medication or use of an epinephrine auto injector.  I acknowledge that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or use of epinephrine auto-injector by the student.

  • I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.

  • I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.

  • I agree the information is shared with school personnel in accordance with the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.

  • I agree to provide the school with back-up medication approved in this form.

  • (Student maintains self-administration record.) 

Parent/Guardian Signature:____________________________   Date: _____/____/___  (agreed to above statement)

Parent/Guardian Address:_____________________________________________                                                   

Home/Cell Phone:______________________Business Phone:____________________ Self-Administration Authorization Additional Information:

 

 

Cross Reference:

     603.3    Special Education

     607.2    Student Health Services

     607.2R1  Student Health Services - Regulation

 

Approved: 2/10/1997                Reviewed:  08/14/2023                   Revised: 08/14/2023

 
Uploaded Files: 
PDF icon tcsd_auth.-asthma_airway_constricting_or_respiratory_distress_medication_self-administration_consent_form.pdf

507.02E2 Tipton Community School District Parental Authorization and Release Form for the Administration of Medication to Students

TIPTON COMMUNITY SCHOOL DISTRICT PARENTAL AUTHORIZATION AND 

RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION TO STUDENTS

Student's Full Name: _____________________     Date of Birth: _________________                 

School: ___________________________________________________________

School medications and health services are administered following these guidelines:

  • Parent has provided a signed, dated authorization to administer prescription medication and/or provide the health service.  Electronic signatures meet the requirement of written signatures.

  • The prescribed medication is in the original, labeled container as dispensed. 

  • The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer and date.

  • Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

 

___________________        _______        _______    ____________

Prescribed Medication          Dosage           Route         Time at School

 

Special Health Services and instructions, if indicted:

____________________________________________________________________________

____________________________________________________________________________ 

Administration instructions

 

____________________________________________________________________________

____________________________________________________________________________  

Special Directives, Signs to Observe and Side Effects

 

_____/_____/_____ 

Discontinue/Re-Evaluate/Follow-up Date

 

 

__________________________                _____/_____/_____ 

Prescriber’s Signature                                     Date

And credentials (when indicated for health service delivery)

 

 

______________________________                ____________ 

Parent's/Guardian Signature                                 Date

 

 

______________________________                ____________

Parent/Guardian address                                    Home/Cell Phone

 

 

______________________________                _____________

Additional Information                                          Business Phone

 

Cross References:

    603.3        Special Education

    607.2        Student Health Services

    607.2R1    Student Health Services - Regulation

 

Approve:  2/10/1997        Reviewed: 08/14/2023        Revised:  08/14/2023

 

 

Uploaded Files: 
PDF icon tcsd_parental_auth._release_for_administration_of_medication_to_students_-_google_docs.pdf

507.02E3 ADMINISTRATION OF MEDICATION TO STUDENTS - PARENTAL AUTHORIZATION

Code No. 507.2E3 

TIPTON COMMUNITY SCHOOL DISTRICT

PARENTAL AUTHORIZATION AND RELEASE FORM FOR INDEPENDENT 

SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR

INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE STUDENT 

 

_________________________________            ___/___/___ _________________ ___/___/___

Student's Name (Last), (First), (Middle)                Birthday         School                          Date 

 

I request the above-named student (Parent/Guardian initial all that apply)

 

 ______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency. The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent. 

 

____________________________________________________________________________Prescribed Medication                Dosage                   Route                    Time at School 

 

______ Co-administer, participate in planning, management and implementation of special health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school. The information provided by the parent for health service delivery is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year. 

 

Special Health Services Delivery: 

 

___________________________________________________________________________

 

___________________________________________________________________________

 

Procedures for abandoned medication disposal shall be in accordance with applicable laws. 

 

____________________________                  ___________________

Prescriber’s Signature                                       Date 

and credentials (when indicated for health service delivery) 

 

 ____________________________                  ___________________ 

Parent/Guardian Signature                                Date

 

__________________________                       _____________________

Parent/Guardian address                                   Home phone

 

Cross Reference:

    603.3      Special Education

    607.2    Student Health Services

    607.2R1  Student Health Services - Regulation

 

Approved: 08/14/2023         Reviewed:  _____________   Revised:  _______________

 

Uploaded Files: 
PDF icon 507.2e3_administration_of_medication_to_students_-_parental_authorization_-_google_docs.pdf

507.02E4 PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADINISTRATION OF VOLUNTARY SCHOOL STOCK OF OVER-THE-COUNTER MEDICATION TO STUDENTS

Code No. 507.2E4

Page 1 of 2

TIPTON COMMUNITY SCHOOL DISTRICT

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION

OF VOLUNTARY SCHOOL STOCK OF OVER-THE-COUNTER MEDICATION TO STUDENTS

 

___________________________       ___/___/___   _________________  ___/___/___

Student's Name (Last), (First), (Middle) Birthday         School                         Date

 

The district supplies the following nonprescription, over-the-counter medications that are listed below. Generic brands may be substituted, (select all that apply):

  • Acetaminophen administered per manufacturer label

  • Throat Lozenges administered per manufacturer label

  • Other: ____________________ administered per manufacturer label (Please Specify)

  • Other: ____________________ administered per manufacturer label (Please Specify)

  • Other:____________________ administered per manufacturer label (Please Specify)

  • Other:____________________ administered per manufacturer label (Please Specify)

 

Voluntary school stock of nonprescription, over-the-counter medications are

administered following these guidelines:

  • Parent has provided a signed, dated annual authorization to administer of the

nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature.

  • The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.

  • All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the counter medication.

  • Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOT applicable.

  • Nonprescription, over-the-counter medications approved by the Federal Drug

Administration that require emergency medical service (EMS) notification after

administration are NOT applicable.

  • Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the department and annual medication administration procedural skills check.

 

O Districts stocking the administration of a voluntary stock of nonprescription, over-the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:

  • when to contact the parent when a nonprescription medication, over the counter medication is administered
  • documentation of the administration of the nonprescription, over-the-counter medication and parent contact;
  • a limit to the administration of a school’s stock nonprescription, over-the-counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school year;
  • the development of an individual health plan for ongoing medication administration or health service delivery at school.

 

I request that the above-named student receive the voluntary stock nonprescription, over-the-counter medications supplied by the school in accordance with the district guidelines and protocol.

 

 

__________________________________________ _________________________

Parent Signature                                                           Date

 

 

__________________________________________ _________________________

Parent/Guardian Address                                              Home Phone

 

 

 

Approved:  08/14/2023               Reviewed:  ______________                 Revised:  ____________

Uploaded Files: 
PDF icon 507.2e4parental_authorization_and_release_form_for_the_administration_of_voluntary_school_stock_of_over-the-counter_medication_to_students_-_google_docs.pdf