AUTHORIZATION ASTHMA OR OTHER AIRWAY CONSTRICTING DISEASE MEDICATION OR EPINEPHRINE

AUTO-INJECTOR SELF-ADMINISTRATION CONSENT FORM 

________________________________             

Student's Name (Last), (First)  (Middle)  

 ___/___/___      

Birthday

_____________________________________________     ___/___/__    

School                                                                                Date  

 

In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who us epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents or guardians and prescribing licensed health care professional regardless of competency.  The following must occur for a student to self-administer asthma medication, bronchodilator canisters or spacers, other airway constricting disease medication or to self-administer an epinephrine auto-injector:

Parent/guardian provides signed, dated authorization for student medication self-administration.

• Parent/guardian provides a written statement from the student’s licensed health care professional (A person licensed under chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under chapter 152 or 152E and registered with the board of nursing, or a physician assistant licensed to practice under the supervision of a physician as authorized in chapters 147 and 148C) containing the following:

  • Name and purpose of the medication,

  • Prescribed dosage, and

  • Times or special circumstances under which the medication or epinephrine auto-injector is to be administered.

• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.

• Authorization shall be renewed annually.  In addition, if any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.

Provided the above requirements are fulfilled, the school shall permit the self-administration of the prescribed medication by a student while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before-school or after-school care on school-operated property. If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

Pursuant to state law, the school district or and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine  auto-injector by the student as provided by law.

 

Authorization-Asthma or Airway Constricting Medication

Self-Administration Consent Form

                                                                                                                                              

Medication                    Dosage             Route                                                   Time

                                                                                                                                              

Purpose of Medication & Administration /Instructions

                                                                                                           /           /           

Special Circumstances                                                                Discontinue/Re-Evaluate/

 Follow-up Date

                                                                                                           /     /     

Prescriber’s Signature                                                                Date 

 

                                                                                                                                               

Prescriber’s Address                                                                  Emergency Phone

 

• I request the above named student possess and self-administer asthma or other airway constricting disease medication(s) and/or an epinephrine auto-injector at school and in school activities according to the authorization and instructions.

• I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or an epinephrine auto-injector or for supervising, monitoring, or interfering with a student's self-administration of medication or use of an epinephrine auto-injector. I acknowledge that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or use of an epinephrine auto-injector by the student.

• I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.

• I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.

• I agree the information is shared with school personnel in accordance with the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.

• I agree to provide the school with back-up medication approved in this form.

 

                                                                                                           /           /           

Parent/Guardian Signature                                                          Date

(agreed to above statement)                                 

                                                                                                                                                 

Parent/Guardian Address                                                            Home Phone

 

                                                                                                                                               

                                                                                               Business Phone

                                                                                                                                              

                                                                                                                                              

                                                                                                                                              

Self-Administration Authorization Additional Information                                                  

                        

 

Approved 9/23/11     Reviewed  8/18/2021              Revised   8-16-23             

_________________________________                      ___/___/___      _________________     ___/___/___

Student's Name (Last), (First),  (Middle)                          Birthday                    School                    Date

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescribed medication and/or provide the special health services listed.  Electronic signatures meet the requirement of written signatures.

• The prescribed medication is in the original, labeled container as dispensed or the manufacturer's labeled container.

• The prescribed medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer and date.

• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

                                                                                                                                                            

Medication/Health Care                      Dosage                        Route                          Time at School

                                                                                                                                              

                                                                                                                                              

Special Health Services and Instructions, as indicated:

                                                                                                                                              

                                                                                                                                              

Special Directives, Signs to Observe and Side Effects

           /           /           

Discontinue/Re-Evaluate/Follow-up Date

                                                                                               /           /           

Prescriber’s Signature                                                   Date

**************************************************************************************************************************

                                                                                                           /           /           

Parent's Signature                                                                    Date 

                                                                                                                                   

Parent's Address                                                                        Phone

                                                                                                                                   

 Additional Information                                                             Business Phone

                                                                                                                                               

                                                                                                                                             

                                                                                                                                              

 

Approved 9/23/11     Reviewed  8/18/2021              Revised   8-16-23         

 

_________________________________      ___/___/___      _________________        ___/___/___ 

Student's Name (Last), (First),  (Middle)          Birthday                School                               Date

I request the above-named student (Parent/Guardian initial all that apply)

______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency.  The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.  I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

____________________________________________________________________________________

Prescribed Medication                       Dosage                     Route                   Time at School 

______ Co-administer, participate in planning, management and implementation of special health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school. The information provided by the parent for health service delivery is confidential as provide by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.  I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise.  I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year.

 Special Health Services Delivery: _________________________________________________________

Procedures for abandoned medication disposal shall be in accordance with applicable laws.

 

_________________________________________                    ______________________

Prescriber’s Signature                                                                                 Date

and credentials (when indicated for health service delivery)

__________________________________________                   ______________________                                                                                                            

Parent/Guardian Signature                                                                           Date 

_______________________________________                        __________________________

Parent/Guardian address                                                                         Home phone

________________________________  ___/___/___ _________________   ___/___/___

Student's Name (Last), (First), (Middle)      Birthday               School           Date

The district supplies the following nonprescription, over-the-counter medications that are listed below. Generic brands may be substituted, (select all that apply:

·       Acetaminophen administered per manufacturer label

·       Throat Lozenges administered per manufacturer label

·       Other: ____________________ administered per manufacturer label (Please Specify)

·       Other: ____________________ administered per manufacturer label (Please Specify)

·       Other: ____________________ administered per manufacturer label (Please Specify)

·       Other: ____________________ administered per manufacturer label (Please Specify)

Voluntary school stock of nonprescription, over-the-counter medications are administered following these guidelines:

• Parent has provided a signed, dated annual authorization to administer the nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature.

• The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.

• All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the counter medication.

• Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOT applicable.

• Nonprescription, over-the-counter medications approved by the Federal Drug Administration that require emergency medical service (EMS) notification after administration are NOT applicable.

• Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the department and annual medication administration procedural skills check.

  • Districts stocking the administration of a voluntary stock of nonprescription, over-the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:

    • when to contact the parent when a nonprescription medication, over the counter medication is administered;

    • documentation of the administration of the nonprescription, over-the-counter medication and parent contact;

    • a limit to the administration of a school’s stock nonprescription, over-the-counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school year;

    • the development of an individual health plan for ongoing medication administration or health service delivery at school.

I request that the above-named student receive the voluntary stock nonprescription, over-the-counter medications supplied by the school in accordance with the district guidelines and protocol.

 

 

__________________________________________    _________________________

Parent Signature                                                                 Date    

 

__________________________________________    _________________________

Parent/Guardian Address                                                    Home Phone                                 

Deleted policy 8/18-2021

 

Some students who require special education need special health services in order to participate in the educational program.  These students will receive special health services in accordance with their individualized health plan.

 

A. Definitions

 

"Assignment and delegation" - occurs when licensed health personnel, in collaboration with the education team, determine the special health services to be provided and the qualifications of individuals performing the health services.  Primary consideration is given to the recommendation of the licensed health personnel.  Each designation considers the student's special health service.  The rationale, in accordance with licensed practice for the designation is documented.  If the designation decision of the team differs from the licensed health professional, team members may file a dissenting opinion in the student’s education record..

"Co-administration" - the eligible student's participation in the planning, management and implementation of the student's special health service and demonstration of proficiency to licensed health personnel.

"Educational program" - includes all school curricular programs and activities both on and off school grounds.

"Education team" - may include the eligible student, the student's parent, administrator, teacher, licensed health personnel, and others involved in the student's educational program, or as described in the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act of 1973..

"Health assessment" - health data collection, observation, analysis, and interpretation relating to the eligible student's educational program.

"Health instruction" - education by licensed health personnel to prepare qualified designated personnel to deliver and perform special health services contained in the eligible student's health plan.  Documentation of education and periodic updates are on file at school.

"Individual health plan" - the confidential, written, preplanned and ongoing special health service in the educational program.  It includes assessment, nursing diagnosis, outcomes, planning, implementation, interventions documentation, evaluation, student goals, if applicable, and a plan for emergencies.  The plan is updated as needed and at least annually.  Licensed health personnel develop this written plan with the collaboration from the parent or guardian, individual’s health care provider or education team. 

"Licensed health personnel" - includes licensed registered nurse, licensed physician, and other licensed health personnel legally authorized to provide special health services and medications under the auspices of the school.

"Prescriber" - licensed health personnel legally authorized to prescribe special health services and medications.

"Qualified designated personnel" - persons instructed, supervised and competent in implementing the eligible student's health plan.

“Special health services" - includes, but is not limited to, services for eligible students whose health status (stable or unstable) requires:

∙ Interpretation or intervention,

∙ Administration of health procedures and health care, or

• Use of a health device to compensate for the reduction or loss of a body function.

"Supervision" - the assessment, delegation, evaluation and documentation of special health services by licensed health personnel.  Levels of supervision include situations in which licensed health personnel are: ∙ physically present.

∙ available at the same site.

∙ available on call.

 

B. Licensed health personnel will provide special health services under the auspices of the school.  Duties of the licensed personnel include the duty to:

• Participate as a member of the education team.

• Provide the health assessment.

• Plan, implement and evaluate the written individual health plan.

• Plan, implement and evaluate special emergency health services.

• Serve as liaison and encourage participation and communication with health service agencies and individuals providing health care.

• Provide health consultation, counseling and instruction with the eligible student, the student's parent and the staff in cooperation and conjunction with the prescriber.

• Maintain a record of special health services.  The documentation includes the eligible student's name, special health service, prescriber or person authorizing, date and time, signature and title of the person providing the special health service and any unusual circumstances in the provision of such services.

• Report unusual circumstances to the parent, school administration, and prescriber.

• Assign and delegate to, instruct, provide technical assistance and supervise qualified designated personnel.

• Update knowledge and skills to meet special health service needs.

 

C. Prior to the provision of special health services the following will be on file:

• Written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated.

• Written statement by the student's parent requesting the provision of the special health service.

• Written report of the preplanning staffing or meeting of the education team.

• Written individual health plan available in the health record or integrated into the IEP or IFSP.

 

D. Licensed health personnel, in collaboration with the education team, will determine the special health services to be provided and the qualifications of individuals performing the special health services.  The documented rationale will include the following:

• Analysis and interpretation of the special health service needs, health status stability, complexity of the service, predictability of the service outcome and risk of improperly performed service.

• Determination that the special health service, task, procedure or function is part of the person's job description.

• Determination of the assignment and delegation based on the student's needs and qualifications of school personnel performing health services.

• Review of the designated person's competency.

• Determination of initial and ongoing level of supervision, monitoring and evaluation required to ensure quality services.

 

E. Licensed health personnel will supervise the special health services, define the level and frequency of supervision and document the supervision.

F. Licensed health personnel will instruct qualified designated personnel to deliver and perform special health services contained in the eligible individual health plan.  Documentation of instruction, written consent of personnel as required in Iowa Code 280.23, and periodic updates are on file at school.

G. Parents will provide the usual equipment, supplies and necessary maintenance for such, unless the school is required to provide the equipment, supplies, and maintenance under the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act of .1973.  The equipment is stored in a secure area.  The personnel responsible for the equipment are designated in the individual health plan.  The individual health plan will designate the role of the school, parents, and others in the provision, supply, storage and maintenance of necessary equipment.

To implement the Wellness Policy, the following district specific goals have been established:

Goal 1 - Nutrition Education and Promotion: Schools will provide nutrition education and engage in nutrition promotion that help students develop lifelong healthy eating behaviors. The goal(s) for addressing nutrition education and nutrition promotion include the following:

● Provide students with the knowledge and skills necessary to promote and protect their health;

● Ensure nutrition education and promotion are not only part of health education classes, but also

integrated into other classroom instruction through subjects such as math, science, language arts, social

sciences, and elective subjects;

● Include enjoyable, developmentally-appropriate, culturally-relevant, and participatory activities, such as

cooking demonstrations or lessons, promotions, taste-testing, farm visits, and school gardens;

● Promote fruits, vegetables, whole-grain products, low-fat and fat-free dairy products, and healthy foods;

● Emphasize caloric balance between food intake and energy expenditure (promotes physical

activity/exercise);

● Link with school meal programs, cafeteria nutrition promotion activities, school gardens, Farm to School

programs, other school foods, and nutrition-related community services;

● Implement evidence-based healthy food promotion techniques through the school meal programs using

Smarter Lunchroom techniques;

● Teach media literacy with an emphasis on food and beverage marketing;

● Include nutrition education training for teachers and other staff; and/or

Goal 2 - Physical Activity: Schools will provide students and staff with age and grade appropriate opportunities to engage in physical activity that meet federal and state guidelines, including the Iowa Healthy Kids Act. The goal(s) for addressing physical activity include the following:

● Develop a comprehensive, school-based physical activity program (CSPAP), that includes the following

components:

● Physical education, recess;

● Classroom-based physical activity;

● Walk to school; and

● Out of school time activities;

● Promote the benefits of a physically active lifestyle and help students develop skills to engage in lifelong

healthy habits;

● Engage students in moderate to vigorous activity during at least 50 percent of physical education class

time;

● Encourage classroom teachers to provide short physical activity breaks (3-5 minutes), as appropriate;

● Encourage teachers to incorporate movement and kinesthetic learning approaches into core subject

instructions when possible;

● Offer classroom health education that complements physical education by reinforcing the knowledge and self-management skills needed to maintain a physically active lifestyle;

● Ensure physical activity is not used for or withheld as a punishment;

● Afford elementary students with recess according to the following:

● At least 20 minutes a day;

● Outdoors as weather and time permits;

● Encourages moderate to vigorous physical activity;

Goal 3 - Other School-Based Activities that Promote Student Wellness: Schools will support student, staff, and parents' efforts to maintain a healthy lifestyle, as appropriate. The goal(s) for addressing other school-based activities that promote student wellness include the following:

● Provide parents a list of foods and beverages that meet nutrition standards for classroom snacks and

celebrations;

● Provide school staff a list of alternative ways to reward children. Foods and beverages will not be used

as a reward, or withheld as punishment;

● Develop a plan to promote staff health and wellness;

● Engage students and parents, through taste-tests of new school meal items and surveys to identify new, healthful, and appealing food choices;

● Share information about the nutritional content of meals with parents and students;

● Support the consumption of breakfast at school by implementing alternative breakfast options to the

extent possible (e.g., grab n' go, breakfast in the classroom, breakfast after 1st period, etc.);

● Permit students to bring and carry water bottles filled with water throughout the day;

● Make drinking water available where school meals are served during mealtimes;

● Encourage fundraising efforts held outside school hours to sell only non-food items, promote physical

activity, or include foods and beverages that meet or exceed the Smart Snacks nutrition standards;

● Strive to provide students with at least 10 minutes to eat after sitting down for breakfast and 20 minutes

after sitting down for lunch;

● Discourage students from sharing foods or beverages during meal or snack times, given concerns about allergies and dietary needs;

● Apply for USDA's Healthier US School Challenge: Smarter Lunchroom Award, a certification initiative that recognizes schools for nutrition and physical activity excellence

Public Involvement: There is a process for permitting parents, students, representatives of the school food authority, teachers of physical education, school health professionals, the school board, administrators and the public to participate in the development, implementation, and periodic review and update of the policy.

● The district has a local wellness policy committee to advise the district on the development,

implementation, and improvement of the school wellness policy;

● The superintendent or superintendent's designee invites suggestions or comments concerning the

development, implementation, and improvement of the school wellness policy. As such, interested

persons are encouraged to contact the superintendent or superintendent's designee; or

NOTE: School districts are required by federal law to have at least one specific wellness goal in each of the goal areas identified above. These goal areas include the following: nutrition promotion and education, physical activity, and other school-based activities that promote student wellness. Options have been provided, but districts must remember the sample policy and sample regulation cannot be adopted in the current format. School boards and administration must make a choice for all text in italicized brackets.

NOTE: The Iowa Department of Education has tools and resources available to help districts with progress reports and other aspects of policy implementation and review. Please visit the "School Wellness Policy" section of the Iowa Department of Education's website, located at:

https://www.educateiowa.gov/pk-12/nutrition-programs/school-wellness

 

Approved: 8/18/2021 Reviewed: _____ Revised: _____