SCHOOL MEDICATION AUTHORIZATION FORM Required for all students Also for the overnight field trips: 5th grade Outdoor E ducation or 8 grade Cleveland Tour PRESCHOOL, K-8TH Elementary School Fax: 708-246-4625 Middle School Fax: 708-352-0092 NAME_______________________________________________________________________GRADE _________________ DOB___________________________ PRESCRIPTION MEDICATION, Dosage and Frequency, Physician Signature
1.__________________________________________________________3.______________________________________________ 2.__________________________________________________________ 4._____________________________________________
“OVER THE COUNTER” Medications approved for student (please checkmark each type for approval): Physician Signature required
Benadryl allergy tabs/(Spray for reaction)
Other__________________________________________________________________________________________________________________
I do not want any medications given to my child during school hours. I understand by checking this space that I am willing to come to school to administer medications as needed. Note - unless specified, dosage will be administered as per directions on medicine container ASTHMA/INHALER SECTION Allergic to________________________________ Medication/Inhaler__________________________________________________________Dosage_____________q______________Hours Neb Treatment- Name/Medication______________________________________________Dosage_____________q______________Hours ASTHMA ACTION PLAN Peak flow meter – My Personal Best = ______________________________ *Green Zone – Breathing is easy, Can play, Work without symptoms* PEAK Flow Range 80%-100% of Personal Best
Medication/Nebulizer______________________________________________Dose______________Freq_________________Hours________ *Yellow Zone- Breathing easy, Coughing or Wheeze, Chest tight, SOB, PEAK Flow Range 50%-80% of Personal Best
Medication/Nebulizer______________________________________________Dose______________Freq_________________Hours________ *Red Zone Medicine NOT working, Nose open wide to breath, Breathing is hard and fast, Trouble walking and talking, Ribs show If Symptoms do not get better Call 911 PEAK Flow Range below 50%
Medication/Nebulizer______________________________________________Dose______________Freq_________________Hours________ EPIPEN EMERGENCY PLAN SECTION Please note: each body system must be filled out Allergic to:___________________________________________________________________________________________ Medication & Dosage: Epipen 0.3mg Epipen Jr. 0.15mg Twinject 0.3mg Twinject 0.15mg Benadryl 25mg- 50mg po Treatment:
Mouth: Itching, tingling, or swelling of lips, tongue, mouth GIVE EPIEN TWINJECT BENADRYL Skin: Hives, itchy rash, swelling of the face or extremities GIVE
Gut: Nausea, abdominal cramps, vomiting, diarrhea GIVE
Throat: Tightening of throat, hoarseness, hacking cough GIVE
Lung: Shortness of breath, repetitive coughing, wheezing GIVE
Heart: Thready pulse, low blood pressure, fainting, pale, blueness GIVE
Other: _______________________________________________ GIVE
If reaction is progressing (several of the above areas affected) GIVE CALL 911 , CALL PRINCIPAL, CALL PARENTS Parent signature below also grants permission for medical release of information to School Nurse to obtain Physician Signature if needed
I hereby confirm my primary responsibility to administer medication to my child. However, in the event that I am unable to do so, I hereby authorize Pleasantdale School District 107 and its employees and agents, in
my behalf, to administer or to attempt to administer to my child(or to allow my child to self-administer, while under the supervision of the employees and agents of the District), lawfully prescribed medication in the manner described above. I acknowledge that it may be necessary for the administration of medications to my child to be performed by an individual other than a registered nurse and specifically consent to such practices. I further acknowledge and agree that, when the lawfully prescribed medication is so administered or attempted to be administered, I waive any claims I might have against the District, its employees and agents arising out of the administration of said medication. In addition, I agree to hold harmless and indemnify the District, its employees and agents, either jointly or severely , from and against
any and all claims, damages, causes of action or injuries incurred or resulting from the administration or attempts of said medication.
This section includes examples of tests for each of the levels described, Basic, Intermediate I, Intermediate II, Advanced I, and Advanced II. The texts are chosen based on their relevance to the professional interests of the students as well as their connection to the material taught in class. The criteria for selecting texts for tests include appropriate content and suitable level. Multiple fac
Hydration and nutrition The BCUHB website has links to the documents and policies described in this leaflet. The effects of dementia on food and fluid intake and hence nutritional status can be considerable. Ongoing nutritional screening and regular monitoring are important. Refer to the Guidance on the use of the Do Not Attempt BCUHB Adult Nutritional Support Policy for guidance on