ASTHMA MEDICATION ADMINISTRATION FORM
ASTHMA PROVIDER MEDICATION ORDER—Office of School Health—School Year ______–______
The Following Section To Be Completed By Student’s Parent/Guardian
I hereby consent to the storage and administration of medication, as well as the storage and use of necessary equipment to administer
medication, in accordance with the instructions of my child's health care practitioner. I understand that I must provide the school with the
medication and equipment necessary to administer medication, including non-Ventolin inhalers. Medication is to be provided in a properly
labeled original container from the pharmacy (another such container should be obtained by me for my child's use outside of school); the label
on the prescription medication must include the name of the student, name and telephone number of the pharmacy, licensed prescriber's name,
date and number of refills, name of medication, dosage, frequency of administration, route of administration and/or other directions; over the
counter medications and drug samples must be in the manufacturer's original container, with the student's name affixed to that container.
I
understand that all provided medication must be supplied in its original and UNOPENED medication box.
I further understand that I must
immediately advise the school nurse of any change in the prescription or instructions stated above.
I understand that no student will be allowed to carry or self-administer controlled substances.
I understand that this consent is only valid
until the end of a New York City Department of Education (“DOE”) sponsored summer instruction program session; or such time that I deliver to
the school nurse a new prescription or instructions issued by my child's health care practitioner (whichever is earlier). By submitting this MAF, I
am requesting that my child be provided specific health services by DOE and the New York City Department of Health and Mental Hygiene
(DOHMH) through the Office of School Health (OSH). I understand that these services may include a clinical assessment and a physical
examination by an OSH health care practitioner. Full and complete instructions regarding the above-requested health service(s) are included in
this MAF. I understand that OSH and their agents, and employees involved in the provision of the above-requested health service(s) are relying
on the accuracy of the information provided in this form. I understand that 30 days before the above-mentioned MAF expiration date, an OSH
health care practitioner may examine my child to evaluate his/her asthma symptoms and my child’s response to the prescribed medication, and
may issue a new MAF. If the OSH health care practitioner determines that no changes to the orders in the MAF are necessary, the OSH health
care practitioner may issue a new MAF with the same orders to expire in one year unless my child’s health care practitioner provides a new
MAF. If an OSH health care practitioner determines based on an examination of my child and pertinent medical history that the orders in the
MAF should be changed, the OSH health care practitioner may issue a new MAF with different orders. I, along with my child’s health care
practitioner of record, will be notified of the issuance of new MAF and of any change in the MAF orders. I further understand that I will have until
30 days before the expiration date of this MAF to submit a new MAF, or to object to this examination in writing, to the school nurse. If I do not
submit a new MAF to the school nurse, or notify the school nurse in writing that I object to my child being examined by an OSH health care
practitioner, by this deadline, my child may be examined and a new MAF may be issued. I recognize that this form is not an agreement by OSH
and DOE to provide the services requested, but rather my request/consent for such services. If it is determined that these services are
necessary, a Student Accommodation Plan may also be necessary and will be completed by the school. I understand that OSH and DOE and
their employees and agents, may contact, consult with and obtain any further information they may deem appropriate relating to my child's
medical condition, medication and/or treatment, from any health care practitioner and/or pharmacist that has provided medical or health services
to my child.
**SELF-ADMINISTRATION OF MEDICATION: Initial below for use of an epinephrine, asthma inhaler and other approved self-administered medications:
`
I hereby certify that my child has been fully instructed and is capable of self-administration of the prescribed medication. I further consent to my
child's carrying, storage and self-administration of the above-prescribed medication in school. I acknowledge that I am responsible for providing
Parent Initials
my child with such medication in containers labeled as described above, for any and all monitoring of my child's use of such medication, and for
any and all consequences of my child's use of such medication in school. I understand that the school nurse will confirm my child’s ability to self-
carry and self-administer in a responsible manner. In addition, I agree to provide “back up” medication in a clearly labeled container to be kept in
the medical room in the event my child does not have sufficient medication to self-administer.
I consent to the school nurse storing and/or administering to my child such medication in the event that my child is temporarily incapable of self-
Parent Initials
storage and self-administration of such medication.
I hereby certify that I have consulted with my child’s health care practitioner and that I consent to the Office of School Health administering
stock medication in the event that my child’s asthma prescription medication is unavailable.
SIGN
Parent Initials
You must send your child’s personal Metered Dose Inhaler (MDI) with your child on a school trip day
HERE
so that he/she has it available. The stock medication is only for use while your child is in the school building.
Student Last Name
First
MI
Date of Birth __ __/__ __/__ __ __ __ School
Print Parent/Guardian’s Name: _________________________
Parent/Guardian’s Signature: ________________________
Date Signed __ __ / __ __ / __ __ __ __ Parent/Guardian’s Address:
Email:
Cell Phone ( _ _ _ ) _ _ _ - _ _ _ _
Other Phone ( _ _ _ ) _ _ _ - _ _ _ _
Email: _____________________________
Alternate Emergency Contact Name: _________________________ Emergency Contact Phone: ( _ _ _ ) _ _ _ - _ _ _ _
For OFFICE OF SCHOOL HEALTH (OSH) Only
Received By Name: ____________________ Date __ __/__ __/__ __
Reviewed By Name: ___________________ Date __ __/__ __/__ __
Self-Administers/Self-Carries:
Yes
No
Services
Nurse
OSH Public Health Advisor*
Supervised Student*
Yes
No
Provided By
School-Based Health Center
OSH Asthma Case Manager*
Signature and Title (RN OR MD/DO/NP): ____________________________________
IEP
Revisions per Office of School Health after consultation with prescribing practitioner:
*Respiratory Distress: includes breathlessness at rest, tachypnea, cyanosis, pallor, hunching forward, nasal flaring, accessory
respiratory muscle use, abdominal breathing, shallow rapid breathing, mouthing words, wheezing throughout expiration and
inspiration or decreased or absent breath sounds, agitation, drowsiness, confusion or exceptionally quiet appearance.
FAX COMPLETED FORMS TO 347-396-8945
.
Confidential information should not be sent by email.
Rev 4/17