TO BE COMPLETED BY THE PHYSICIAN. The Montgomery County Department of Health and Human Services and the Montgomery County Public Schools discourage the administration of medication to students in school during the school day. Any necessary medication that possibly can be administered before and after school should be so prescribed. Only non-parenteral medications are administered except in specific emergency situations. School personnel will, when it is absolutely necessary, administer medication to students during the school day and while participating in outdoor education programs and overnight field trips, according to the procedures outlined on the back of this form. PLEASE USE A SEPARATE FORM FOR EACH MEDICATION Name of Medication: Diagnosis: Trade name and/or generic Dosage: Time(s) To Be Given At School: Route of Administration: Effective Dates: From / / To / / Side Effects: If PRN, specify: When indicated (signs/symptoms) Frequency of administration - - / / Physician’s Name (print/type) Physician Signature Phone Number DateSELF-CARRY/SELF-ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL Self-carry/self-administration of emergency medication such as inhalers and EpiPens® must be authorized by the prescriber and be approved by the school nurse according to the State medication policy: Prescriber’s authorization for self-carry/self-administration of emergency medication / / Signature Date School RN approval for self-carry/self-administration of emergency medication / / Signature Date PART III—TO BE COMPLETED BY THE PRINCIPAL OR SCHOOL NURSE Check as appropriate: Parts I and II above are completed, including signatures. (It is acceptable if all items of information in Part II are written on the physician’s stationery/prescription blank.) Prescription medication is properly labeled by a pharmacist. Medication label and physician order are consistent. Over-the-counter medication is in an original container with the manufacturer’s dosage label and safety seal intact. / / Date any unused medication is to be collected by the parent or guardian (within one week after expiration of the physician’s order). / / Principal/School Nurse Signature Date MCPS Form 525-13, Rev. 1/06 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES
TO BE COMPLETED BY THE PHYSICIAN. I understand that treatments may be administered in MCPS by non-health professionals. These individuals may be employees of MCPS who volunteer to administer the treatment(s), or the DHHS School Health Room Aide. These persons will be trained by the School Community Health Nurse to give the specific treatment. Student Name Diagnosis Treatment Frequency and time(s) to be provided at school If not needed on a routine basis, specify when indicated Treatment orders effective: / / To / / Possible complications and/or special considerations Equipment needed for treatment, including any special care and handling Symptoms/observations to be reported List other condition(s) and/or diagnosis(es) of student that staff need to be aware of / / Physician’s Name (Print or type) Telephone Original Signature, Physician Date
TO BE COMPLETED BY THE PHYSICIAN. (For over-the-counter medication for 3 days not prescribed by a physician or for an antibiotic for less than 10 days, Part II must be completed by a parent or guardian; in these instances a physician signature is not required.) Any necessary medication that possibly can be taken before or aVer school should be so prescribed. Injectable medications are not facilitated in school except in specific emergency situations and scheduled insulin injections. School personnel will, when it is absolutely necessary, facilitate the use of medication during the schoolday and while participating in outdoor educationprograms and overnights. Diagnosis
TO BE COMPLETED BY THE PHYSICIAN. Emergency injections may be administered in Manassas City Public Schools by nonhealth professionals. These persons are taught by the school health nurse to administer the injection. For this reason, only Epipen Auto Injectors or Epipen Jrs. may be given. It should be noted that these staff members are not trained observers and therefore cannot observe for the development of symptoms before administering the injections. Administer the following injection immediately after report of exposure to: (Indicate Specific Allergen(s) and Signs and Symptoms to Observe For) Check as appropriate: Xxx-xxx Xx. or Auvi-Q Give the premeasured dose of 0.15 mg epinephrine 1:2000 aqueous solution. (0.3 cc). Repeat dose in 15 minutes if rescue squad has not arrived. (Two kits will be needed in school.) Epi-pen or Auvi-Q Give the premeasured dose 0.3 mg epinephrine 1:1000 aqueous solution. (0.3 cc). Repeat dose in 15 minutes if rescue squad has not arrived. (Two kits will be needed in school.) Remarks: Note: Medication expiration date must be clearly indicated. Physician’s Name (Print or Type) Physician’s Signature Phone # Date PART III – TO BE COMPLETED BY THE PRINCIPAL OR PRINCIPAL DESIGNEE Parts I and II above are completed including signatures and medication is properly labeled by a pharmacist. Principal or Principal Designee’s Signature Date ORIGINAL: Student Health/Medical History Record
TO BE COMPLETED BY THE PHYSICIAN. Emergency injections may be administered in Manassas Park Schools by nonhealth professionals. These persons are taught by the school health nurse to administer the injection. For this reason, only Epipen Auto Injectors or Epipen Jrs. may be given. It should be noted that these staff members are not trained observers and therefore cannot observe for the development of symptoms before administering the injections. Administer the following injection immediately after report of exposure to: (Indicate Specific Allergen(s) and Signs and Symptoms to Observe For) Check as appropriate: Xxx-xxx Xx. Give the premeasured dose of 0.15 mg epinephrine 1:2000 aqueous solution. (0.3 cc). Repeat dose in 15 minutes if rescue squad has not arrived. (Two kits will be needed in school.) Epi-pen Give the premeasured dose 0.3 mg epinephrine 1:1000 aqueous solution. (0.3 cc). Repeat dose in 15 minutes if rescue squad has not arrived. (Two kits will be needed in school.)
TO BE COMPLETED BY THE PHYSICIAN. Providing information requested on this report will assist Northern Credit Union in planning our employee’s return to work. The patient/employee agrees to the provision of this information as evidence by his/her signature in Section I. Name of Physician: Address of Physician: Date of Examination: In my opinion, the employee has a: work injury or illness non-work related injury or illness recurrence of a previous injury or illness condition not related to a work injury or illness uncertain because: In my opinion, the above named person is able to return to work subject to the following restrictions In my opinion, the above named person is incapable, by reason of illness or injury, of working: Yes No In my opinion, the above named person will or will not be able to attend work regularly. Estimated date of return to duty: Attending Physician’s Signature: Date: APPENDIX B NEW: RE: FUTURE DEVELOPMENT OF NORTHERN CREDIT UNION LIMITED The Employer and the Union recognize that it may be in the best interest of the Credit Union, its members, and its employees, to merge, amalgamate, or enter into other types of strategic arrangements with other Financial Institutions.
TO BE COMPLETED BY THE PHYSICIAN. The above-named attendee has been instructed in the proper use of his/her asthma inhaler/emergency medication. The attendee’s well-being is in jeopardy unless this medication is carried on his/her person. Therefore, I request that he/she be permitted to carry the asthma inhaler/emergency medication during this recreational program. He/she understands the purpose, appropriate method and frequency of use of the asthma inhaler/emergency medication. NAME OF MEDICATION: PHYSICIAN’S SIGNATURE: DATE: TO BE COMPLETED BY THE PARENT/GUARDIAN: I permit my child to carry the above-listed asthma inhaler/emergency medication as ordered by his/her physician. PARENT/GUARDIAN SIGNATURE: DATE:
