Authorization to Administer
Prescribed Medication
Release and Indemnification Agreement
MONTGOMERY COUNTY PUBLIC SCHOOLS |
MCPS Form 525-13 |
MONTGOMERY COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES |
February 2019 |
Rockville, Maryland 20850 |
Page 1 of 2 |
PART I: TO BE COMPLETED BY THE PARENT/GUARDIAN
I hereby request and authorize Montgomery County Public Schools (MCPS) and Montgomery County Department of Health and Human Services (DHHS) personnel to administer prescribed medication as directed by an authorized prescriber (Part II below). I agree to release, indemnify, and hold harmless MCPS and DHHS and any of their officers, staff members, or agents from lawsuit, claim, demand, or action against them for administering prescribed medication to this student, provided MCPS and DHHS staff are following the authorized prescriber’s order as written in Part II below. I have read the procedures outlined on the back of this form and assume the responsibilities as required.
Student Name: Last ____________________________________________________________________ First___________________________________ MI____
MCPS ID#_________ Date of Birth ____/____/_____ School Name _______________________________________________________________________
Prescription: o Renewal o New If new, the first full day’s dosage was given at home on: ____/____/_____
List all medication(s) student is taking, including over-the-counter medication(s):
Signature, Parent/Guardian ______________________________________________________________ Phone ____-____-______ Date ____/____/_____
PART II: TO BE COMPLETED BY THE AUTHORIZED PRESCRIBER
DHHS and MCPS discourage the administration of medication to students in school during the school day. Any necessary medication that possibly can be administered before and after school should be so prescribed. Only non-parenteral medications are administered except in specific emergency situations. School personnel will, when it is absolutely necessary, administer medication to students during the school day and while participating in outdoor education programs and overnight field trips, according to the procedures outlined on the back of this form.
PLEASE USE A SEPARATE FORM FOR EACH MEDICATION
Name of Medication (trade name or generic): _________________________________________________ Diagnosis:______________________________
Dosage: _________________________________________________________ Time(s) to be given at school:_____________________________________
Ranges not accepted (i.e., 1 to 2 tabs or 2 to 4 puffs)
Route of Administration: __________________________________________________________________________________________________________
Medication orders effective o Current school year, OR o Effective dates ____/____/_____ to ____/____/_____
Side Effects: _____________________________________________________________________________________________________________________
If PRN, specify when indicated (signs/symptoms) ____________________________________________________________________________________
Frequency of administration (ranges not accepted, i.e. every 2 to 4 hours) ____________________________________________________________
Authorized Prescriber’s Name (print/type)_______________________________________________ Phone ____-____-______ Date ____/____/_____
Authorized Prescriber Signature____________________________________________________________________________________________________
SELF-CARRY/SELF-ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL
Self-carry/self-administration of emergency medication such as inhalers and epinephrine auto-injectors must be authorized by the authorized prescriber and be approved by the school nurse according to the Maryland State School Health Services Guidelines.
Authorized prescriber’s authorization for self-carry/self-administration of emergency medication
Signature ________________________________________________________________________________________________Date ____/____/_____
School Nurse (RN) approval for self-carry/self-administration of emergency medication
Signature ________________________________________________________________________________________________Date ____/____/_____
PART III: TO BE COMPLETED BY THE SCHOOL COMMUNITY HEALTH NURSE OR PRINCIPAL
Check as appropriate:
o Parts I and II above are completed, including signatures. (It is acceptable if all items of information in Part II are written on the authorized prescriber’s stationery/prescription form)
o Prescription medication is properly labeled by a pharmacist.
o Medication label and authorized prescriber order are consistent.
o Over-the-counter medication is in an original container with the manufacturer’s dosage label and safety seal intact.
____/____/_____ Date any unused medication is to be collected by the parent/guardian (within one week after expiration of the
authorized prescriber’s order).
Signature, School Community Health Nurse (SCHN)/Principal ___________________________________________ Date ____/____/_____
MCPS Form 525-13
Page 2 of 2
INFORMATION AND PROCEDURES
1.No medication will be administered in school or during school-sponsored activities without the parent’s/guardian’s written authorization and a written authorized prescriber order. This includes both prescription and over-the-counter (OTC) medications.
2.This form must be completed for medication administration in school. MCPS Form 525-14, Emergency Care for the Management of a Student with a Diagnosis of Anaphylaxis, Release and Indemnification Agreement for Epinephrine Auto Injector, is preferred for epinephrine auto-injectors.
3.The parent/guardian is responsible for completing Part I and obtaining the authorized prescriber’s statement on Part II. This is required every school year for each new or continuing order or if there is a change in dosage or time of administration during the school year. (A authorized prescriber may use office stationery or prescription pad in lieu of completing Part II.) Information necessary includes: student’s name, diagnosis, medication name, dosage, time of administration, route of administration, duration of medication order, possible side effects, authorized prescriber signature, and date.
4.The medication must be delivered to the school by the parent/guardian or, under special circumstances, an adult designated by the parent/guardian. Under no circumstances will either school health (DHHS) or school (MCPS) personnel administer medication brought to school by the student.
5.All prescription medication must be provided in a container with the pharmacist’s label attached. Non-prescription OTC medication must be in the original container with the manufacturer’s dosage label and safety seal intact. Authorized prescriber samples must be appropriately labeled by the authorized prescriber.
6.The first day’s dosage of any new non-emergency medication must have been given at home before it can be administered at school.
7.The parent/guardian is responsible for collecting any unused portion of a medication within one week after expiration of the authorized prescriber’s order or at the end of the school year. Medication not claimed within that time period will be destroyed.
8.Self-administered and/or non-medically prescribed medications are entirely the responsibility of the parent/guardian and not that of either MCPS or DHHS. Medications without accompanying authorized prescriber’s orders and parent/guardian consent will not be stored in the health room.
9.Students may not self-administer controlled substances.
10. An authorized prescriber’s order and parent/guardian permission are necessary for self-carry/self- administered emergency medications such as inhalers for asthma and epinephrine auto-injector for anaphylaxis. The school nurse must evaluate and approve the student’s ability and capability to self-administer medication. It is imperative the student understands the necessity for reporting to either the health staff or MCPS staff members that they have self-administered their inhaler without any improvement or have self-administered an epinephrine auto injector, so 911 may be called.
11. The school nurse will call the authorized prescriber, as allowed by the Health Insurance Portability and Accountability Act (HIPAA), if a question arises about the student and/or the student’s medication.
