Wareham middle school
The following are regulations regarding administration of medications in the Wareham School
System. No medications will be administered unless these guidelines are followed.
Whenever possible, medications should be given at home with every effort made to avoid
administration during school hours. PHYSICIAN-PARENT/GUARDIAN RESPONSIBILITY 1.
A parent or guardian must bring the medication to the school nurse's office. Do not send any
medications to school with your child.
This includes aspirin, Tylenol and cough preparations, (drops,
lozenges, cough medications) as well as prescription drugs. The Nurse will document the quantity of
medication received on the Medication Administration log.
The medication authorization form must be completed and signed by both a parent/guardian and a
physician request form if the medication is not received in a properly labeled prescription bottle with a current date. 3.
The parent/guardian authorization form is acceptable without a signed physician request if the
medication is received in a properly labeled prescription bottle with a current date. 4.
All medication - prescriptions or otherwise - must be in a container with the original label and
The School Health Department does not provide aspirin, Tylenol, cough medicines or other over the
counter products. These will not be administered without a doctor's order. Students with asthma may be allowed to carry their emergency inhalator with them provided:
a. the prescription label is on the canister b. the physician/parent (guardian) form is signed and on file with the nurse indicating the doctor
feels that the medical situation and the child's knowledge of his/her medical needs warrants the carrying of the medication
Administration of Epinephrine in Life Threatening Situation
Wareham Public Schools are registered with the Massachusetts Department of Public Health for the limited purpose of permitting unlicensed, properly trained, school personnel to administer epinephrine (by auto-injector) to students with a diagnosed life threatening allergic condition when a school nurse (RN) is not immediately available.
The unlicensed school personnel authorized to administer epinephrine are trained by a physician
or school nurse (RN) and are tested for competency, in accordance with standards and a curriculum established by Massachusetts Department of Public Health. The school nurse documents the training and testing competency.
The school nurse provides a training review and informational update for unlicensed personnel at
The school maintains a list of unlicensed school personnel authorized and trained to administer
epinephrine in an emergency, when a school nurse is not immediately available.
Epinephrine is administered only in accordance with a written medication administration plan
developed by the school nurse, satisfying the requirements of 105 CMR 210.005(E) and 210.009(A) (6), and updated annually, which includes the following:
a. Diagnosis by a physician that the student is at high risk of a life-threatening allergic reaction,
and a medication order containing indications for administration of epinephrine.
b. Written authorization by a parent or guardian. c. Home and emergency phone number(s) for the parent/guardian, as well as the name(s) and
of any other person(s) to be notified if the parents are unavailable.
d. Names of school personnel who have received training in administration of epinephrine by
auto-injector to the individual student.
e. Identification of places where the epinephrine is to be stored, following consideration of the
need for storage at places where the student may be most at risk. The epinephrine may be stored at more than one location or carried by the student when appropriate.
f. Consideration of the ways and places epinephrine can be stored so as to limit access to
appropriate persons, which shall not require the epinephrine to be kept under lock and key. Epi-Pens will be available in the main office at each school building.
g. Plan for risk reduction for the student, including a plan for teaching self-management, where
When epinephrine is administrated, there shall be immediate notification of the local emergency medical services system generally (911) followed by notification of the school nurse, the student’s parents or, if the parents are not available, any other designated person(s), and the student’s physician. This policy is in accordance with the Massachusetts Department of Public Health Regulations 105 CMR 210.000: The Administration of Prescription Medications In Public and Private Schools. For further discussion on the topic of medication administration, please refer to The Comprehensive School Health Manual published by the MDPH (1995), Chapter 6 “Nursing Practice in the School Setting”, pp. 6-8 to 6-32. ADOPTED: MARCH 8, 1989 Review by SCPRSCP 2/5/92 Review by Elizabeth S. Dunn, RN 5/14/92 AMENDED: SEPTEMBER 23, 1992 Reviewed by SCPRSCP 5/2/00 Reviewed by SCPRSCP 11/7/00 Amended by SCPRSCP December 5, 2000 AMENDED: DECEMBER 13, 2000 Reviewed by SCPRSCP 11/12/02 Reviewed by SCPRSCP 2/11/03 AMENDED: FEBRUARY 26, 2003 Reviewed by SCPRSCP 2/5/08 AMENDED: MARCH 12, 2008 Reviewed by SCPRSCP 11/4/08 AMENDED: NOVEMBER 12, 2008 Reviewed by SCPRSCP 1/18/11 AMENDED: JANUARY 27, 2011 WAREHAM PUBLIC SCHOOLS, WAREHAM, MASSACHUSETTS
AUTHORIZATION FOR EPINEPHRINE ADMINISTRATION
PARENT OR GUARDIAN I request that ____________________________ be given _____________________________
as prescribed by __________________________at __________________________________ Physician’s Name
I give my permission when a school nurse is not available, for the Principal or his/her designee to administer the medication. I accept full responsibility and relieve the Wareham School System, school personnel, and the Town of Wareham of any liability regarding the administration. ________________________________
ALLERGY:__________________________________________________ Parent/Guardian _______________________________________________ Home # _______________________________________ Work # _________________________ Emergency contact to be notified if parents are unavailable: ______________________________________ _____________________________________ Name
______________________________________ _____________________________________ Name
Medication Order for Anaphylaxis
To be completed by a Licensed Prescriber:
Physician, Nurse Practitioner, or others Authorized by Chapter 94C
Name of Student___________________________________________________DOB___/____/_____ Address _________________________________________________________Grade ____________ Name of Licensed Prescriber ____________________________________Title ___________________ Business Telephone # ___________________ Emergency Telephone # _____________________ Type of Allergy ____________________________________________________________________ Other Medical Condition(s) * __________________________________________________________ Other Medications Taken by Student *___________________________________________________
□ Do when signs/symptoms of allergic reaction appear.
□ 1) Administer Oral Benadryl ________________ c.c./ mg. p.o. □ 2) If signs/ symptoms worsen or are unresolved with oral Benadryl within ____ min or ORAL BENADRYL NOT ORDERED please administer :
□ 3) If signs/ symptoms worsen or are unresolved with Epi-Pen/ Epi-Pen JR. s.c. within __________ min administer repeat dose of:
Life threatening allergic reactions are given epinephrine immediately. 911 called whenever epinephrine is administered.
Other order(s) __________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
Special side effects, contraindications, or possible adverse reactions to be observed:___________ ______________________________________________________________________________Consent for self-administration (provided that R.N. determines it is safe and appropriate) Yes _____ No ______
_______________________________________________________ ______________________ Prescriber Signature Date * If not in violation of confidentiality May 20, 99
Dear Parent/Guardian: According to your child’s health record, your child has an allergy to _______________. Due to the unpredictable nature and serious consequences of an allergic reaction we want to be prepared in the event your child is exposed to the allergen.
Allergic reactions can occur at any time and reactions that may have been minimal in the past can become
life threatening without warning. In the case of food allergies, the specific allergen that causes your child’s allergy may be used in another food and your child would not be aware of it until they had an allergic reaction.
For those reasons we request that you discuss your child’s reaction with your health care provider to
determine the best treatment plan for your child. The Wareham School District requires the following completed forms be on file in your child’s health record:
1. Signed medication order for oral Benadryl and/or EpiPen(Jr) from your health care provider. 2. Signed consent form for oral Benadryl and/or EpiPen(Jr) from a parent/guardian. We recommend that the parent/guardian meet directly with the school nurse to complete the protocols that
outline the care to be provided to your child in the event of an allergic reaction. Each health office has oral Benadryl available for student use. If your child requires an EpiPen, we require that you provide the school with at least one kit for your child’s personal use.
Due to the seriousness of the situation, we request that you act quickly to ensure the appropriate
documentation from your health care provider. We will work in collaboration with your child’s teacher(s) school administration, and staff to provide your child with the safest school environment possible. If you have any questions, please contact your school nurse.
Middle/Coop School (508) 291-3550 ext. 6108
East/Hammond School (508) 291-3586 ext. 12
AUTHORIZATION FOR MEDICATION ADMINISTRATION
PARENT OR GUARDIAN
I request that ___________________________be given _____________________________
Child's Full Name Name of Medication
as prescribed by _________________________at __________________________________
Physician's Name Time of Day
I give my permission when a school nurse is not available, for the Principal or his/her designee to
administer the medication.
I accept full responsibility and relieve the Wareham School System, school personnel, and the Town of
Wareham of any liability regarding the administration.
This section must be completed for any medication not in a labeled prescription bottle.
I request that __________________________ receive the following:
Name of Child
Name of Medication: ________________________________ Dosage:__________________
Time to be taken during school hours:_____________________________________________
Duration of treatment:_________________________________________________________
Possible side effects and adverse reactions:_________________________________________
Signature of Physician Print Name
______________________________ _____________________________________ Telephone Number Date
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