Common use of TO BE COMPLETED BY THE PHYSICIAN Clause in Contracts

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. The Montgomery Xxxxxxxxxx County Department of Health and Human Services and the Montgomery Xxxxxxxxxx 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. The Montgomery Xxxxxxxxxx County Department of Health and Human Services and the Montgomery Xxxxxxxxxx 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 DosagegenericDosage: Time(s) To Be Given At School: Ranges not accepted (i.e. 1 to 2 tabs or 2 to 4 puffs) Route of Administration: Effective Dates: From / / To / / Side Effects: If PRN, specify: When indicated (signs/symptoms) Frequency of administration Ranges not accepted (i.e. every 2 to 4 hours) - - / / Physician’s Name (print/type) Physician Signature Phone Number DateSELFDate SELF-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 Registered Nurse (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 12/14 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES

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 MEDICATIONName of Medication: Diagnosis: Trade name and/or generic DosagegenericDosage: Time(s) To Be Given At School: Route Ranges not accepted (i.e. 1 to 2 tabs or 2 to 4 puffs)Route of Administration: Effective Dates: From / / To / / Side Effects: If PRN, specify: When indicated (signs/symptoms) Frequency of administration Ranges not accepted (i.e. every 2 to 4 hours) - - / / Physician’s Name (print/type) Physician Signature Phone Number DateSELFDate SELF-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 Registered Nurse (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 12/14 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES

TO BE COMPLETED BY THE PHYSICIAN. The Montgomery Xxxxxxxxxx County Department of Health and Human Services and the Montgomery Xxxxxxxxxx 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 MEDICATIONName of Medication: Diagnosis: Trade name and/or generic DosagegenericDosage: Time(s) To Be Given At School: Route Ranges not accepted (i.e. 1 to 2 tabs or 2 to 4 puffs)Route of Administration: Effective Dates: From / / To / / Side Effects: If PRN, specify: When indicated (signs/symptoms) Frequency of administration Ranges not accepted (i.e. every 2 to 4 hours) - - / / Physician’s Name (print/type) Physician Signature Phone Number DateSELFDate SELF-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 Registered Nurse (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 12/14 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES

TO BE COMPLETED BY THE PHYSICIAN. The Montgomery Xxxxxxxxxx County Department of Health and Human Services and the Montgomery Xxxxxxxxxx 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 DosagegenericDosage: Time(s) To Be Given At School: Ranges not accepted (i.e. 1 to 2 tabs or 2 to 4 puffs) Route of Administration: Effective Dates: From / / To / / Side Effects: If PRN, specify: When indicated (signs/symptoms) Frequency of administration Ranges not accepted (i.e. every 2 to 4 hours) - - / / Physician’s Name (print/type) Physician Signature Phone Number DateSELFDate SELF-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 Registered Nurse (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 1/13 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES

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 MEDICATIONName of Medication: Diagnosis: Trade name and/or generic DosagegenericDosage: Time(s) To Be Given At School: Route Ranges not accepted (i.e. 1 to 2 tabs or 2 to 4 puffs)Route of Administration: Effective Dates: From / / To / / Side Effects: If PRN, specify: When indicated (signs/symptoms) Frequency of administration Ranges not accepted (i.e. every 2 to 4 hours) - - / / Physician’s Name (print/type) Physician Signature Phone Number DateSELFDate SELF-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 Registered Nurse (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 1/13 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES

TO BE COMPLETED BY THE PHYSICIAN. The Montgomery Xxxxxxxxxx County Department of Health and Human Services and the Montgomery Xxxxxxxxxx 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 DateSELFDate SELF-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 Registered Nurse (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 11/11 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES

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 DateSELFDate SELF-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 Registered Nurse (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 11/11 DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian INFORMATION AND PROCEDURES