Form SS/SE-63 at a glance
What it is: Medication Authorization, a Release and Indemnification Agreement that the parent or guardian completes.
Who signs: Part I: Parent or Guardian Signature, Daytime Telephone and Date.
The parent or guardian authorizes 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. The parent or guardian agrees 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 licensed prescriber, parent or guardian orders set forth in accordance with the provision of Part II.
The parent or guardian completes and signs Part II for over-the-counter medication per manufacturer's recommendation for relief of symptoms for headache, muscle ache, orthodontic pain, or menstrual cramps for the entire school year. Over-the-counter medications for symptoms other than headache, muscle aches, menstrual cramps, orthodonic pain, including antibiotics, and antiviral medications may be given for ten consecutive schooldays with only the parent or guardian's signature. Licensed prescriber must complete and sign for all other medications.
Any medication taken in school or SACC must have a parent or guardian-signed authorization; some medications also require licensed prescriber's orders.
A licensed prescriber may use office stationery or a prescription pad in lieu of completing Part II.
What to bring and attach to Form SS/SE-63
All prescription medications, including licensed prescriber's prescription drug samples, must be in their original containers and labeled by a licensed prescriber or pharmacist in English.
The pharmacy label must match the authorization.
Non-prescription medication should always be kept in the original, unopened bottle or box with the name of the medication visible and no more than 100 pills/tablets/capsules.
The following information must be included on the OTC label for the original container: Name of student, Route of administration, Exact dosage to be taken in school (e.g., mg, ml), Frequency or time interval dosage is to be administered.
The parent or guardian must provide FCPS and SACC a supply of medication to be administered during the school day and in SACC.
Only a 30-day supply of medication should be brought into school at a time.
A filled-in Form SS/SE-63 example: a parent authorizes an over-the-counter medication
How to fill out Form SS/SE-63, box by box
Student Name
Enter the student's Name: Last, First and Middle.
Date of Birth, School Name, School Year and Grade
Enter the Date of Birth, School Name, School Year and Grade.
Has the student taken this medication before and First dose was given
Mark Yes or No: has the student taken this medication before? If no, the first full dose must be given at home to ensure that the student does not have a negative reaction, and then enter the Date and Time the First dose was given.
The first dose of any new medication must be given at home with the exception for a rescue medication.
Parent or Guardian Signature, Daytime Telephone and Date
Part I: Parent or Guardian Signature, Daytime Telephone and Date.
I give permission for the Public Health Nurse (PHN) to contact the licensed prescriber named in Part II to clarify information provided on the order should the need arise.
Diagnosis, Medication and Route
Enter the Diagnosis.
Enter the Medication and its Route (Oral, Injection, Inhalation, Topical, Buccal, Rectal, etc.)
If medication is given on an as-needed basis
If medication is given on an as-needed basis, specify the symptoms or conditions when medication is to be taken and the time between doses.
Dosage to be given at school or SACC and Time(s) or interval between doses
Enter the Dosage to be given at school or SACC, (e.g. mg, ml) and the Time(s) or interval between doses.
Effective Date
Under Effective Date, mark Current School Year OR fill in From and To.
If the student is taking more than one medication for the same symptom(s)
If the student is taking more than one medication for the same symptom(s), list sequence in which medications are to be taken.
Licensed Prescriber Name, Signature, Telephone or Fax and Date
Print or Type the Licensed Prescriber Name, then add the Licensed Prescriber Signature, Telephone or Fax and Date.
Parent or Guardian Name, Signature, Telephone and Date in Part II
Print or Type the Parent or Guardian Name (Not required if licensed prescriber signs).
Sign Parent or Guardian Signature in Part II, and enter the Telephone and Date.
More rules for Form SS/SE-63
Use a separate form for each medication.
No medication will be accepted by school or SACC personnel without receipt of completed and appropriate medication forms.
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.
Medication must be kept in the school health room or other school-approved location during the school day.
Medication kept in the school will be stored in a locked area accessible only to authorized personnel.
The student is to come to the school health room, or to a predetermined location, at the prescribed time to receive medication.
Medication can be given no more than one half hour before or after the prescribed time.
Within one week after expiration of this authorization, discontinuation of medication or on the last day of school, the parent or guardian must pick up any unused portion of the medication; medications not claimed within that period will be destroyed.
Common questions about Form SS/SE-63
Is there a deadline?
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.
When is this form not the right one?
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.
Sources
[1] Form SS/SE-63 (5/25), Medication Authorization, Fairfax County Public Schools (the Official source link on this page).