Medical Information and Medical Forms

Just a Reminder to All Parents of Students who may need to use an inhaler, epi-pen or other prescribed medication at school.  A Doctors' order is required for a nurse to give any of these medications at school. 

Here is a link to the Medication Guidelines used by CESU Nurse's.
STUDENT MEDICATION GUIDELINES

The PRESCRIPTION MEDICATION ORDER AND PERMISSION FORM needs to be filled out by your child's pediatrician before medication can be given at school. 

Prescription Medication Order and Permission Form

If your child has an allergy, that requires the use of an 'EPI-Pen', I need an "Allergy or Emergency Action Plan" filled out by your allergist or PCP.

Here is a link to an Emergency Action Plan that your PCP may or may not choose to use. Many offices have their own version of an Allergy or Emergency Action Plan they like to use.

Allergy/ Emergency Action Plan

If your child has Asthma, I will need an "Asthma Action Plan" filled out by your PCP.  

Asthma Action Plan 

Please send these in to me ASAP.

Any medications that are sent in to school need to be in their original containers, along with the Medication order from your child's physician.

Any over the counter medication that you send in for your child to use at school needs to:
  1. Be in the original container.
  2. Needs to have a note with parental permission for the medication to be given at school, include   in the note the last time that you gave this medication at home.
  3. Be brought to school by the parent or guardian and given to the school nurse or an appropriate   adult. For safety reasons, no medication should be brought in by the student. 

If you have any questions, please feel free to contact me. 
   

Chittenden East Supervisory Union

PRESCRIPTION MEDICATION ORDER AND PERMISSION FORM

To be forwarded to the School Nurse

Date ___________________________

I hereby give my permission to ______________________________________ to release

Physician’s Name

information to _________________________________________ concerning medication

School Name

prescribed for ________________________________________.

Name of Student

I also give my permission for the above named student to take the medication, as prescribed below, at school.

Signature of Parent or Guardian_________________________________________

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Medication ______________________________________________________________

Directions _______________________________________________________________

Beginning Date ________________________Last Dose____________________________

Reason for Giving__________________________________________________________

Signature of Physician _____________________________________________________________

Emergency Medications This student is capable of, and has been instructed by the physician in, the proper method of self administration of this medication. He/she has been advised of possible side effects of the medication and has been informed of when and how to access emergency services. Self administration of this medication can only occur with both parent/guardian and physician signatures. Student may carry and self-administer this medication.        Yes __No__ Student needs to bring this medication on all half-day and full day field trips.Yes__ No___ Signature of Physician ___________________________________________________________________ Signature of Parent or Guardian __________________________________________________________

 

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No medication will be given at school until the school receives this completed form with the

prescribed medication in its original container, appropriately labeled by the pharmacy or physician. All medicine brought into the school must be kept in the Health Office during school hours unless noted above.

Date Received __________ Signature of School Nurse ____________________________

The school and its employees and agents, including volunteers are hereby released from liability as a result of any injury arising from the student’s self administration of the emergency medication, except when the conduct of the school, school employee or agent would constitute gross negligence, recklessness or intentional misconduct.

                                                                                                                                                                       

2013