StudentMedicationProcedure
BiloxiPublicSchoolsMedicationPolicy
Nostudentwillbeallowedtobringmedicinetoschool,
exceptforapprovedasthmainhalersandauto-injectableepinephrinepens.
*ThepreferenceoftheBiloxiPublicSchoolsisnevertoadministeraprescriptionmedicationtoastudent;butweunderstandthatattimesthereareemergenciesthatjustifydispensingprescriptiondrugs.
*Medicationprescribedbyalicenseddoctor/nursepractitionercanbeadministeredtostudentsatschoolifnecessary.Noover-the-counterornarcoticmedicationwillbeadministeredatschool.Ifastudentisillandtakingover-the-countermedication,he/sheshouldremainathome,ortheparentmaycometotheschooltogivethemedication..
*Whenadoctorprescribesamedication,theparentmustarrangewithadoctorforthechildtoreceivethemedicationattimesotherthanduringschoolhours.Ifthedoctorfeelsitisnecessaryforthemedicationtobe
givenatschool,theparentmustadheretothefollowingprocedure:
1.Nostudentwillbeallowedtobringanymedicinetoschoolandtakeitwithoutschoolofficepersonnelsupervision;
allmedicationmustbebroughttotheschoolbytheparent/guardianwithoneexception,asnotedin#5and#6below.
2.Intheeventamedicationisbroughttotheschoolbyastudent,themedicinewillbeimmediatelyconfiscatedandthestudentmaybereferredtothebuildingadministratorfordisciplinaryaction,withtheexceptionof#5and#6below.
3.Theparentmustbringthemedicationtotheschoolintheoriginalprescriptionbottle,whichmustbelabeledas
prescribedbylaw.Onlyprescriptionmedicationwillbedispensedatschool.
4.Thewrittenconsentformmustbesignedbytheparentandreturnedtotheschoolbeforeanymedicationwillbedispensedtothechild.
5.Astudentmaycarryaninhalerforasthmaiforderedbytheirphysicianornursepractitioner.Writtenpermissionsigned
bythephysician/providerandparentmustbedocumentedonthedistrictform,AsthmaActionPlan.Thisformmustbereturnedtotheschoolnurse.
6.Astudentmaycarryauto-injectableephinephrineiforderedbytheirphysicianornursepractioner.Writtenpermissionsignedbythephysician/providerandparentmustbedocumentedonthedistrictform,AnaphylaxisActionPlan.Thisformmustbereturnedtotheschoolnurse.
7.Itistheparent'sresponsibilitytotransportmedicationtothein-schoolsuspensionlocationshouldhis/herchildbeassignedtoin-schoolsuspensionasaresultofadisciplinaryinfraction.
Notes: A.Allmedicationdispensedmustbedonebyapprovedschoolofficepersonnelwiththeexceptionofasthmainhalersandauto-injectableephinephrine.
B.Itistheresponsibilityofthestudenttakingmedicationtokeepupwithhis/hermedicationtime.
ParentRequestForPrescriptionDrugDispensation
NameofMedicationSpecificDosetoAdminister
SpecificTime(s)toAdministerDatetoAdministerFirstDoseDatetoEndMedicationReasonforMedication
* Itistheresponsibilityoftheparenttoinsurethatadequatemedicationisavailableattheschool.
Parent/GuardianSignatureTelephone
OfficialApprovalDate
THISFORMISTOBESIGNEDBYTHESCHOOLNURSEORSCHOOLPRINCIPALANDKEPTONFILEBYTHENURSE.BPSrev05-12
SchoolMedicationPrescriberParentAuthorizationStudentInformation
Student’sName
SchoolGrade
TeacherYear
ListanyknownDrugAllergies/Reactions
HeightWeight(lbs)
PrescriberInformation
Nameofmedication
MedicalDiagnosis
DosageFrequency/TimetobegivenRoute
DatetobeginmedicationDatetoendmedication
SpecialInstructions
1.Doesmedicationrequirerefrigeration?Yes orNo
2.Isthemedicationacontrolledsubstance?Yes orNo
3.IsSelf-Medicationpermittedrecommendedforthisstudent?Yes orNo
4.Ifasthmainhalerormedicationisanauto-injectableepinephrine,doyourecommendthismedicationbekept“onperson”bythestudent? Yes or No
PotentialSideEffects/Contraindications/AdverseReactions
PhysicianTreatmentOrderintheeventofanadversereaction
SignatureofPrescriberDatePhoneFaxParentAuthorization
IauthorizetheSchoolPrincipalorhisdesigneetoassignunlicensedschoolpersonnelwhohascompletedtheMississippiBoardofNursingAssistedSelfAdministrationCurriculumthetaskofassistingmychildintakingtheabovemedication.Iunderstandthatadditionalparent/prescribersignedstatementswillbenecessaryifthedosageofmedicationischanged.IalsoauthorizetheSchoolNursetotalkwiththephysicianorpharmacistshouldaquestioncomeupaboutthemedication.FieldTripmedicationistheparent/guardianresponsibility.
Medicationmustberegisteredbytheschoolnurse.Itmustbeintheoriginalcontainerandbeproperlylabeledwiththestudent’sname,prescriber’sname,dateofprescription,nameofmedication,dosage,strength,timeinterval,routeofadministration,anddateofexpiration.
Date
SignatureofParent/Guardian