Microsoft word - asthma rx self administration.pdf

MOBERLY
SCHOOL
DISTRICT
Health
Services
 
 
 
 
 
 
 
 
 
 
 
 
 
 School
Year________
 ASTHMA MEDICATION SELF-ADMINISTRATION FORM

Student Name: _________________________________________________Grade: __________Date of Birth________________
The Missouri Safe Schools Act of 1996 provides for students to carry and self-administer life-saving medications when the following criteria are met: 1) Written authorization by the parent/guardian 2) Medical history of students asthma on file at the school 3) Written asthma action plan/individual healthcare plan on file at school 4) Written authorization from the prescribing physician that child has asthma or is at risk of having anaphylaxis, has been trained in the use of the medication and is capable of self-administration of the medication. THIS MEDICATION AUTHORIZATION IS ONLY VALID FOR THE CURRENT SCHOOL YEAR
MEDICATION NAME _____________________________________ Dose ________________ Time or Interval _______________
Route/Inhalation device _____________________________________________Instructions _________________________________
____________________________________________________________________________________________________________
Important Note: May repeat use of short-acting bronchodilator dose 2-6 puffs (i.e. Albuterol) with a spacer/spacer with mask every 20
minutes for 2 treatments if asthma symptoms are not improving (Expert Panel Report-EPR3, 2007 National Asthma Guidelines).
Notify school staff if one dose fails to relieve symptoms.
MEDICATION NAME _____________________________________ Dose ________________ Time or Interval _______________
Route/Inhalation device _____________________________________________Instructions _________________________________
____________________________________________________________________________________________________________
If epinephrine, notify staff immediately when used. May repeat dose of epinephrine in 10-15 minutes if symptoms are not
resolving.
ALLERGIES: list known allergies to medications, foods, or air-borne substances ______________________________________
I, the parent or legal guardian of the student listed above, give permission for this child to carry and self-administer the above listed
medications. I have instructed my child to notify the school staff if one dose fails to relieve asthma symptoms in 20 minutes or does
not sustain my child for 3 or more hours. My child understands to notify school staff imediately if epinephrine is used so 911 can be
called. I acknowledge that the school district and its employees or agents shall incur no liability as a result of any injury arising from
the self-administration of medication by my child or the administration of such medication by school staff.
Signature of parent or legal guardian _____________________________________________________ Date _________________
Parent/Guardian:
Name: ___________________________________________________________________ Phone:______________________

Emergency Contact:
Name: ____________________________________________________________________ Phone: ___________________________
I, a licensed health care provider, certify that this child has a medical history of asthma and/or anaphylaxis, has been trained in the use
of the listed medication, and is judged to be capable of carrying and self-administering the listed medication(s). The child should
notify school staff if one dose of the medication fails to relieve asthma symptoms in 20 minutes or sustain the child for at least 3
hours. This child understands the hazards of sharing medications with others and has agreed to refrain from this practice.
Signature of Health Care Provider_______________________________________________________ Date _________________
Health Care Provider:
Name: ______________________________________________________________________________________________________
Fax: _____________________________________________________ Phone: ____________________________________________ Address: _________________________________________________________City: __________________________Zip: _________ Notifications: teacher bus driver office Notes on reverse side

Source: http://moberly.k12.mo.us/Forms/health/Asthma%20Rx%20Self%20Administration.pdf