BRIMFIELD -
Phone: 1-508-867-8774 Fax: 1-508-867-0320
Dear
Parent/Guardian:
We
would like to inform you of the policies that have been put in place to ensure
the health and safety of children needing medicines during the school day.
Our
school district requires that the following forms must be on file in your
child's health record before we begin to give any medicine at school:
1. Signed
consent by the parent or guardian to give the medicine. Please complete
the enclosed consent
form and give it to your school nurse.
2. Signed medication order. The written medication order form should be
taken to your child's licensed health care provider (your child's physician,
nurse practitioner, etc.) for completion and returned to the school nurse. This order must be renewed as needed and at the beginning of each
academic year.
Medicines
must be delivered to the school in a pharmacy or manufacturer-labeled container
by you or a responsible adult whom you designate. Please ask your pharmacy to provide separate
bottles for school and home. No more
than a thirty-day supply of the medicine should be delivered to the school.
When
your child needs a medicine to be given during the school day, please act
quickly to follow these policies so we may begin to give the medicine as soon
as possible. Thank you for your help.
Sincerely,
Elaine
Gittens, RN, BSN
School
Nurse
Attachments: Medication Order
Written Parent/Guardian
Consent
BRIMFIELD -
Phone: 1-508-867-8774 Fax: 1-508-867-0320
MEDICATION
ORDER
(To
be completed by a Licensed Prescriber: Physician, Nurse Practitioner, or other
authorized by Chapter 94C)
Name
of student ___________________________________Date of Birth _________________
Address
_______________________________________________Grade __________________
(street) (city/town)
Name
of Licensed Prescriber ____________________________________Title ______________
Business
Telephone # _______________________Emergency Telephone # _________________
Medication
____________________________________________________________________
Route
of administration ________________________________Dosage ____________________
Frequency
________________Time(s) of Administration _______________________________
Please
note: Whenever possible, medication should be scheduled at times other than
school hours.
Specific
directions or information for administration
___________________________________
Date
of Order ___________________Discontinuation Date _____________________________
Consent for self-administration (provided
the school nurse determines it is safe and appropriate). (Yes) ____________ (No) _____________
Diagnosis*
____________________________________________________________________
Any
other medical condition(s)* ___________________________________________________
Optional
Information
1.
Special side effects, contraindications, or possible adverse reactions to be
observed:
______________________________________________________________________________
2.
Other medication being taken by the student:
_______________________________________
__________________________________________
Signature
of Licensed Prescriber
*If
not in violation of confidentiality.
BRIMFIELD -
Phone: 1-508-867-8774 Fax: 1-508-867-0320
General
Information
Name of Student: ____________________________School: __________________________Grade:____________
Date of Birth: _____________________________Sex: ___________________
Name of Parent/Guardian: _______________________________________________________________________
(Please Print)
Address: _____________________________________________________________________________________
Tel. Number (Home): _________________________Tel. Number (Work):________________________________
Tel. Number (Where parent/guardian can be reached in case of emergency): _______________________________
Other Persons, if any, to be notified in case of emergency if parent/guardian is unavailable:
Name: _________________________________________Telephone:_____________________________________
Relationship: ____________________________________
My son/daughter is currently receiving the following medications (to be completed if not in violation of confidentiality): (Please list all medicines the child is receiving, including those given during the school day).
1. ___________________2. _____________________3. ____________________4. ________________________
My son/daughter is known to have the following allergies: ____________________________________________________________________________________________
Consent
1. I give permission to have the school nurse or school personnel designated by the school nurse give the following medicine________________________________ prescribed by _________________________________________
(Name of Medicine) (Licensed Prescriber)
to __________________________________________________________________________________________
(Name of Student)
2. I give permission
for my son/daughter to self-administer medication if the school nurse
determines it is safe and appropriate.
(Yes) __________
(No) ___________
3. I give permission to the school nurse to share with appropriate school personnel information relative to the prescribed medicine administration, e.g., adverse side effects, as she/he determines necessary for my child's health and safety.
(Yes) ____________ (No) __________ Any restrictions on release: _____________________________________
Please note: I understand that I may retrieve the medicine from the school at any time and that the medicine will be destroyed if it is not picked up within one week following the termination of the order or one week beyond the close of school).
__________________________________________ ___________________________ ______/______/________
Parent/Guardian Signature Relationship to Student Date