Authorization for Self-Administration of Medication
E 5141.21
AUTHORIZATION FOR
SELF-ADMINISTRATION OF MEDICATION
SEE ATTACHMENT FOR DOWNLOADABLE FORMS
Pursuant to AS 14.30.141, the Ketchikan Gateway Borough School District (the District) shall permit the self-administration of medication(s) by a pupil during the current school year upon the terms and conditions of this Authorization and by completing Exhibit 5141.21 (e).
1. Authorization. The undersigned hereby authorize the self-administration of medication for asthma or anaphylaxis (medication(s)) by the pupil identified below and, if applicable, the storage of any medication(s) at school.
2. Licensed Health Professional Certification. For purposes of this Authorization, licensed health professional means a licensed physician, advanced nurse practitioner, physician’s assistant, village health aide, or pharmacist operating within the scope of the licensed health professional’s authority. Attached to this Authorization is written certification from the pupil’s licensed health professional that the pupil:
- Has asthma or a condition that may lead to anaphylaxis;
- Has received instruction in the proper method of administration of the medication(s); and,
- Has demonstrated to the licensed health professional the skill necessary to use the medication(s) and any device used to administer the medication(s) as prescribed.
3. Written Treatment Plan. Attached to this Authorization is a written treatment plan signed by the pupil’s licensed health professional for managing asthma and anaphylaxis episodes and including
- A list and dosage of medication(s); and,
- Instructions on the storage of any medication(s) at school.
4. Release, Indemnity and Hold Harmless. The undersigned hereby release the District from all claims, liability and expense, whether caused in whole or in part by the District, its employees or agents, which may in any way arise out of or result from the self-administration or storage of medications including, but not limited to, claims for property damage and personal injury, including death. The undersigned further agree to defend and hold harmless the District, its employees and agents from and against any and all liability and expense which may in any way arise out of or result from the self-administration or the storage of the medication(s).
1. Notice of Non-Liability. Pursuant to AS 14.30.141(b), written notice is hereby given that the District, its employees and agents have no liability related to the self-administration or storage of medication(s) under AS 14.30.141.
2. Prescribed Use. It is understood that if the pupil uses the medication(s) other than as prescribed, including allowing another pupil to use the medication(s), disciplinary action may be imposed on the pupil; however, the imposed disciplinary action may not limit or restrict the pupil’s immediate access to the medication(s).
Student’s Name: Birthdate:
School: Grade:
THIS PORTION TO BE COMPLETED BY THE PARENT/GUARDIAN
Medication
Dosage
Directions
Reason for Medication:
Possible side effects of medication:
Procedure in case of Emergency due to side effects:
I request/authorize the school name d above to administer medication to the above named student in accordance with the over-the-counter medication package instructions. I understand that the medication must be in the manufacturers original packaging to be accepted by the school for administration. I understand that every effort will be made by school staff to administer the medication in a timely manner.
THIS AUTHORIZATION IS VALID FROM (date) to (date) (not to exceed the current school year.)
Student has been instructed and is capable of self-carry and administration of the over-the-counter medication: Applicable for grades 7-12 only Yes No
All other grades will need to check medication in at the school office.
Signature: Date:
TO BE COMPLETED BY SCHOOL PERSONNEL
Authorization is hereby accepted by Ketchikan Gateway Borough School District. The above named medications are are not stored at the school.
Signature: Date:
Printed Name and Title:
Copy of School Board Policy given to parent/guardian
E 5141.21(c)
AUTHORIZATION
FOR
EMERGENCY ADMINISTRATION OF MEDICATION
The Ketchikan Gateway Borough School District (the District) provides for the self-administration of medication for asthma and anaphylaxis as set forth in a separate “Authorization of Prescribed and/or Emergency Medication” form (Exhibit 5141.21 (e). This Authorization is for administration of medication in those instances where the pupil is not able to self-administer and permits District personnel to administer medication in such emergencies subject to the terms and conditions of this Authorization.
1. Authorization. The undersigned hereby authorize the emergency administration of medication for asthma or anaphylaxis (medication) to the pupil identified below and, if applicable, the storage of any medication(s) at school.
2. Licensed Health Professional Certification. For purposes of this Authorization, licensed health professional means a licensed physician, advanced nurse practitioner, physician’s assistant, village health aide, or pharmacist operating within the scope of the licensed health professional’s authority. Attached to this Authorization is written certification from the pupil’s licensed health professional that the pupil has asthma or a condition that may lead to anaphylaxis.
3. Written Treatment Plan. Attached to this Authorization is a written treatment plan signed by the pupil’s licensed health professional for managing emergency asthma and anaphylaxis episodes and including
a. A list and dosage of medication(s); and,
b. Instructions on the storage of any medication(s) at school.
4. Release, Indemnity and Hold Harmless. The undersigned hereby release the District from all claims, liability and expense, whether caused in whole or in part by the District, its employees or agents, which may in any way arise out of or result from the administration or storage of medications including, but not limited to, claims for property damage and personal injury, including death. The undersigned further agree to defend and hold harmless the District, its employees and agents from and against any and all liability and expense which may in any way arise out of or result from the administration or the storage of the medication(s).
5. Notice of Non-Liability. Notice is hereby given that the District, its employees and agents have no liability related to the administration or storage of medication(s).
6. Prescribed Use. It is understood that if the pupil uses the medication(s) other than as prescribed, including allowing another pupil to use the medication(s), disciplinary action may be imposed on the pupil; however, the imposed disciplinary action may not limit or restrict the pupil’s immediate access to the medication(s).
Student’s Name: Birthdate:
School: Grade:
THIS PORTION TO BE COMPLETED BY THE LICENSED HEALTH PROFESSIONAL (LHP)
Medication
Dosage
Directions
Reason for Medication:
Possible side effects of medication:
Procedure in case of Emergency due to side effects:
I authorize and request the above named student be administered the above identified medication in accordance with the instructions indicated above as there exists a valid health reason which makes the administration of the medication advisable during school hours.
THIS AUTHORIZATION IS VALID FROM (date) to (date)
(not to exceed the current school year.)
Student has been instructed and is capable of self-administration of asthma and/or anaphalaxis medication:
LHP signature: Date:
LHP printed name: Phone:
THIS PORTION TO BE COMPLETED BY THE PARENT/GUARDIAN
I request/authorize the school named above to administer medication to the above named student in accordance with the Licensed Health Professional’s instructions. I understand that every effort will be made by school staff to administer the medication in a timely manner.
If the Physician and School Nurse gives permission to self carry inhaler or self-admimister medication: Do you give authorization for your child to: Carry and administer inhaler and/or anaphylaxis medication? Yes No
Signature: Date:
TO BE COMPLETED BY SCHOOL PERSONNEL
Authorization is hereby accepted by Ketchikan Gateway Borough School District. The above named medications are are not stored at the school.
Signature: Date:
Printed Name and Title:
Copy of School Board Policy given to parent/guardian
E 5141.21(e)
AUTHORIZATION OF
OVER THE COUNTER MEDICATION AT SCHOOL
Student’s Name: Birthdate:
School: Grade:
THIS PORTION TO BE COMPLETED BY THE PARENT/GUARDIAN
Medication
Dosage
Directions
Reason for Medication:
Possible side effects of medication:
Procedure in case of Emergency due to side effects:
THIS AUTHORIZATION IS VALID FROM (date) to (date) (not to exceed the current school year.)
I request/authorize the school named above to administer medication to the above named student in accordance with the over-the-counter medication package instructions. I understand that the medication must be in the manufacturer’s original packaging to be accepted by the school for administration. I understand that every effort will be made by school staff to administer the medication in a timely manner.
Student has been instructed and is capable of self-carry and administration of the over-the-counter medication: Applicable for grades 7-12 only Yes No
All other grades will need to check medication in at the school office.
Signature: Date:
TO BE COMPLETED BY SCHOOL PERSONNEL
Authorization is hereby accepted by Ketchikan Gateway Borough School District. The above named medications are not stored at the school.
Signature: Date:
Printed Name and Title:
Copy of School Board Policy given to parent/guardian
KETCHIKAN GATEWAY BOROUGH SCHOOL DISTRICT
Revision Date: 11/18/2010
Revision Date: 9/23/2015