WINDSOR PUBLIC SCHOOLS

Windsor, Connecticut

AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINES BY SCHOOL PERSONNEL

The Connecticut State law and regulations require a physician's written order and parent or guardian's authorization for a nurse to administer medicinal preparations or, in her/his absence, the principal or teacher to administer medications. (Section 10-212a)

Name of Child________________________________________Date_________________________

Address_____________________________________________ Date of Birth__________________

Condition for which medication is being administered_____________________________________

_________________________________________________________________________________

Name of Medication ________________________________________________________________

Amount of Medication ____________________________Time of Administration _______________

Relevant side effects to be observed, if any _____________________________________________

_________________________________________________________________________________

Other suggestions _________________________________________________________________

Length of time during which medication shall be administered:

From ____________________________ to __________________________ (Dates)
(Limited to current school year)

____________________________ M.D.______________________________ __________________
        Signature of Physician                                   Address                                   Phone

_____________________________________________ ____________________________________
                 Signature of Parent/Guardian                                                 School

Medication should be in the original prescription container labeled with the date, name of drug, dosage, interval and physician's name and prescription number.

____________________________________________________________________________________
____________________________________________________________________________________

AUTHORIZATION FOR THE DISPOSAL OF ABOVE MEDICINE BY SCHOOL PERSONNEL

I hereby give permission to school personnel to destroy the above medication if not picked up by me within one week of a request to do so.

____________________________________
        Signature of Parent/Guardian

FOR SCHOOL USE ONLY:

Date _____________________________ Signature _________________________________________
                                                                                              Laurel O'Brien, Head Nurse

REV. 3/98