Fairfax Medication Authorization Form – Fill Out and Use This PDF

MEDICATION AUTHORIZATION

Release and Indemnification Agreement

PLEASE READ INFORMATION AND PROCEDURES ON REVERSE SIDE

PART I PARENT OR GUARDIAN TO COMPLETE

I hereby request Fairfax County Public Schools (FCPS), Fairfax County Health Department (FCHD), and School Age Child Care (SACC) personnel to administer medication as directed by this authorization. I agree to release, indemnify, and hold harmless FCPS, FCHD, SACC, and any of their officers, staff members, or agents from lawsuits, claims, expenses, demands, or actions, etc., against them for helping this student use medication, provided FCPS, FCHD, and SACC staff members comply with the physician, parent or guardian orders set forth in accordance with the provision of part II below. I have read the procedures outlined on the back of this form and assume responsibility as required.

Has the student taken	Yes	No	(If no, the first full dose must be given at home to ensure that the student does not have a negative reaction.)
this medication before?			First dose was given: Date		Time

Student Name (Last, First, Middle)

No School Board employee, public health nurse, or school health aide shall administer medication or treatment, as an exception under School Board policy, unless the principal or his or her designee has personally reviewed all the required clearances.

Parent or Guardian Signature

Daytime Telephone

Date

PART II PARENT OR GUARDIAN TO COMPLETE AND SIGN FOR OVER-THE-COUNTER MEDICATION FOR RELIEF OF SYMPTOMS FOR HEADACHE, MUSCLE ACHE, ORTHODONTIC PAIN, OR MENSTRUAL CRAMPS AND FOR ANTIBIOTIC AND ANTIVIRAL MEDICATION. PHYSICIAN MUST COMPLETE AND SIGN FOR ALL OTHER MEDICATIONS.

The Fairfax County Health Department and Fairfax County Public Schools discourage the use of medication by students in school during the school day. Any necessary medication that possibly can be taken before or after school should be so prescribed. Injectable medications are not administered in schools except in specific emergency situations. School personnel will, when it is absolutely necessary, administer medication during the school day and while participating in outdoor education programs and overnight field trips and school crisis situations according to the procedures outlined on the back of the form. Information should be written in lay language with no abbreviations.

Diagnosis

Medications

If medication is given on an as-needed basis, specify the symptoms or conditions when medication is to be taken and the time at which it may be given again.

Physician Name (Print or Type)		Physician Signature		Telephone or Fax		Date
Parent or Guardian Name (Print or Type)		Parent or Guardian Signature		Telephone		Date
(Not required if physician signs)

PART III PRINCIPAL OR PRINCIPAL DESIGNEE TO COMPLETE

Check √ as appropriate

Parts I and II above are complete including signatures. (It is acceptable if all items in part II are written on the physician's stationery or a prescription pad.)

Principal or Designee Signature

Date

Information from the Fairfax County Public Schools student scholastic record is released on the condition that the recipient agrees not to permit any other party to have access to such information without the written consent of the parent, guardian, or eligible student.

SS/SE-63 7/13

Distribution: Original-School, Copy-Parent or Guardian

PARENT INFORMATION ABOUT MEDICATION PROCEDURES

1.Medications should be taken at home whenever possible so that the student will not lose valuable classroom time or have a shortened lunch period. Any medication taken in school or SACC must have a parent or guardian-signed authorization; some medications also require physician orders. Medication must be kept in the school health room or other school-approved location during the school day. The parent or guardian must transport medications to and from school, except a high school student may carry an over-the-counter medication to and from the school health room.

2.No medication will be accepted by school or SACC personnel without receipt of completed and appropriate medication forms.

3.A physician may use office stationery or a prescription pad in lieu of completing part II. Include the following information written in lay language with no abbreviations:

-Name of student

-Date of birth

-Reason for medication or diagnosis

-Name of medication

-Exact dosage to be taken in school, (e.g. milligrams per tablet, milligrams per ml/cc) as applicable

-Time to take medication and frequency or exact time interval dosage is to be administered

-Sequence in which the medications should be taken in cases where more than one medication is prescribed

-If medication is given on an as-needed basis, specify the exact conditions or symptoms when medication is to be taken and the time at which it may be given again. (“Repeat as necessary” is unacceptable.)

-Duration of medication order or effective dates

-Physician's signature

-Date

4.All prescription medications, including physician's prescription drug samples, must be in their original containers and labeled by a physician or pharmacist. An over-the-counter medication must be in the original container with the name of the medication visible. The parent or guardian must label the original container with the following:

-Name of student

-Exact dosage to be taken in school (e.g. milligrams per tablet, milligrams per ml/cc)

-Frequency or time interval dosage is to be administered

5.The first dose of any new medication must be given at home.

6.The parent or guardian is responsible for submitting a new form to the school and to SACC at the start of the school year and each time there is a change in the dosage or in the time at which medication is to be taken.

7.Medication kept in the school will be stored in a locked area accessible only to authorized personnel.

8.Within one week after expiration of the effective date on the physician order, or on the last day of school, the parent or guardian must personally collect any unused portion of the medication. Medications not claimed within that period will be destroyed.

9.The student is to come to the school health room, or to a predetermined location, at the prescribed time to receive medication. Parents should develop a plan with the student to ensure that the student goes to the school health room at the appropriate time. Medication can be given no more than one half hour before or after the prescribed time.

10.The Fairfax County Health Department, Fairfax County Public Schools, and Fairfax County School Age Child Care do not assume responsibility for authorized medication taken independently by the student.

11.In no case may any health, school, or SACC staff member administer any medication outside the framework of the procedures outlined here and/or in FCPS regulations.

SS/SE-63 7/13

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