Asthma Medication Administration Form - Office Of School Health (Page 2 of 2) in pdf

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.

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

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

Services

Nurse

OSH Public Health Advisor*

Supervised Student*

Yes

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

Asthma Medication Administration Form - Office Of School Health Page 2

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