Microsoft word - health update and otc form 2009-2010.doc

2009–10 Health Update and Permission to Give Over-The-Counter Medication
Please complete a separate form for each student and return it to the School in an
envelope marked “School Nurse” by August 1, 2009. Please attach an updated
immunization record. This mandatory form must be completed and signed by a parent and on
file in the clinic prior to the administration of over-the-counter medication to a student. Student Name_______________________________________________ D.O.B.___________ Entering grade_____ New or Returning? (circle) Are there any medical issues that may affect school performance or require attention during the school year? YES or NO (circle) If yes, please detail here _______________________________________________________________________________________________ Daily medication taken at home _____________________________________ Food allergies _______________________________________ Drug allergies ______________________________________ Other allergies ____________________________________________________ Are any of the above allergies potentially life-threatening to your knowledge? Yes No Not sure N/A (circle one) Comments _________________________________________________________________________________________________________ Physician _____________________________________________________ Phone ______________________________________________ PERMISSION TO ADMINISTER OVER-THE-COUNTER (OTC) MEDICATIONS AT SCHOOL
ADVIL®/ MOTRIN® (or generic equivalent – ibuprofen) TYLENOL® (or generic equivalent – acetaminophen) REGULAR TUMS® (for minor stomach upsets) BENADRYL® liquid or tablets (for allergic reaction only) BENADRYL® or HYDROCORTISONE 1% CREAM (for anti-itch use) NEOSPORIN® or POLYSPORIN OINTMENT (or generic equivalent) REFRESH PLUS ® EYE DROPS or contact lens solution HALL’S® COUGH DROPS (for Middle School students only)
By signing and dating this form, I agree that:
The school nurse will assess the student’s need for OTC medication before administering any of the above, and medication dosages will be calculated strictly according to product directions and weight of student. The first dose of any medication may not be given at school, and I affirm that before today, my child has been administered the OTC medications for which permission is being granted. If a student has frequent headaches, stomach aches, etc., the school nurse may require a physician's order before further administration of an If I want my child to receive an OTC medication not listed above, I must bring it to the clinic and complete the appropriate form before the The school nurse and/or teachers are not permitted to administer any medications/supplements/vitamins that are not FDA approved. Standard precautions will be made to protect my child's privacy. However, I agree that information that may affect my child’s safety may be released to teachers on a "need to know basis." I agree to notify the School of any changes in my child's health status between this date and the end of the school year. My child, named above, has permission to receive the above named OTC medications from the school nurse or authorized substitute. Parent Signature _____________________________________________Date ____________ Relationship to student____________________ Mother's name ____________________________________ Emergency contact #s________________________________________________ Father's name ____________________________________ Emergency contact #s ________________________________________________ If my child is ill and parents cannot be reached, the following people may pick up my child and assume responsibility for his/her care: Name __________________________________Phone #s ___________________________________Relationship to student_______________ Name __________________________________Phone #s ___________________________________Relationship to student_______________

Source: http://www.robs.org/ftpimages/162/misc/misc_66183.pdf