TULSA PUBLIC SCHOOLS

HEALTH SERVICES

AUTHORIZATION FOR THE ADMINISTRATION OF MEDICATION BY DESIGNATED SCHOOL PERSONNEL

Oklahoma law states that the school nurse, administrator or other designated school employee shall not be liable to the students, parent or guardian of the student for civil damages for any personal injuries to the student which result from omission of the school nurse, administrator or other designated school employee in administering any medicine pursuant to the provisions of the law except for acts or omissions constituting gross, willful or wanton negligence.

Medication will be given to a student only with the written permission of a parent, the legal guardian or person responsible for student’s care. Designated employees may not administer medications requiring invasive routes. Over the counter medications must be in original packaging with printed dosages appropriate for age or weight. Prescription medication must be in a currently dated prescription vial or properly labeled container which correctly states the student’s name, the name of the physician or dentist and directions for administering the medication. Aspirin (acetylsalicylic acid) may only be administered with written permission of the physician or dentist. A new authorization form must be filled out for each change of medication and renewed each school year. Medication that is not reclaimed by the last official day of school closing will be destroyed, according to policy. The regulations on administering medication to students are available, upon request.

Student Name________________________________________________________________________________    Birthdate________________________

Home Address_______________________________________________________________________________    Telephone _______________________

 School_______________________________________________________  Grade________________________    Emergency Telephone______________

PHYSICIAN OR DENTIST ORDER

Diagnosis Requiring Medication______________________________________

Name of Medication #1____________________________________________

Time and amount to be given__________________a.m.__________________p.m.

Date: From________________________To _______________________

Date of Prescription _____________Discontinuation Date_____________

Intended Effect of Medication________________________________________

Side effects to Expect__________________________________________

                   to Report__________________________________________

If there are side effects, plan of management_______________________

Is this a controlled drug?_______________________________________

                                 (controlled drugs cannot be transported by a minor)

Physician’s/Dentist’s Name (Type or Print)_________________________________________

 Office Phone________________Emergency Phone__________________

 Address_____________________________________________________

Physician’s/Dentist’s Signature (if required)_________________________________________

AUTHORIZATION BY PARENT/GUARDIAN for the administration of the above medication by school personnel:

I hereby authorize Tulsa Public Schools and its designated employees to administer to my child lawfully prescribed medication in the manner described above. I ACKNOWLEDGE THAT IT MAY BE PERFORMED BY AN INDIVIDUAL OTHER THAN A SCHOOL NURSE, AND SPECIFICALLY CONSENT TO SUCH PRACTICES. I acknowledge and agree that I waive any claims that I might have against the School District, its employees and agents arising out of the administration of said medicine. I agree to hold harmless its designated employees from and against any and all claims, damages, causes of action or injuries incurred or resulting from the administration, attempts at administration or omissions of said medicine pursuant to the provisions of Oklahoma law, except for acts or omissions constituting gross, willful, or wanton negligence. I further authorize the school nurse and/or designated employee to contact the above named physician(s)/dentist(s) for medical information relevant to the care of the student during school and/or school sponsored activities.

Signature of Parent/Legal Guardian or Person Responsible for Student’s Care:

 ________________________________________________________________________________Date___________________ 

Relationship to student______________________________________Address_________________________________________

Home Phone_______________________________     Emergency Name______________________________________________

Work Phone_______________________________     Emergency Phone_____________________________________________