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District of Columbia Medication and Treatment Authorization Form

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District of Columbia Medication and Treatment Authorization Form
District of Columbia Medication and Treatment Authorization Form
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HEALTH
School Health Program
AUTHORIZATION FOR MEDICATION ADMINISTRATION FORM
NAME OF STUDENT: __________________________________________________ DOB: ______________________________
SCHOOL: _____________________________________ SOC. SEC. #_________________ Grade: ____________________
PART I:
PARENT/GUARDIAN CONSENT FORM
Parent/Guardian:
Please complete and sign this action.
I hereby request and authorize the School Nurse/Licensed Practical Nurse/Trained Certified DCPS Personnel to
administer prescribed medication as directed by the physician to ___________________________________________.
STUDENT’S NAME
I have read the procedures on the reverse side of this form and agree to assume the responsibilities as required.
This medication is a
new or renewal prescription. If new prescription, enter date and time the first dose
was given at home.
Date: _________________________ Time: ______________ A.M/P.M.
_______________________________________________________________ __________________________________________
SIGNATURE OF PARENT/GUARDIAN RELATIONSHIP
_____________________________________________________
______________________________________________________
PLEASE PRINT NAME DATE
PLEASE TAKE THIS FORM TO STUDENT’S PHYSICIAN FOR COMPLETION
PART II:
PHYSICIAN’S MEDICATION AUTHORIZATION ORDER
Physician:
Please complete and sign this action. Original Renewal Change
NAME OF STUDENT: _______________________________________________ DOB::_________________________________
ADDRESS: ________________________________________________________ TEL. NO.:______________________________
DIAGNOSIS: _______________________________________________________________________________________________
NAME OF MEDICATION: ____________________________________________________________________________________
DOSE::_____________________________________________________________________________________________________
TIME & CIRCUMSTANCES OF ADMINISTRATION AT SCHOOL: ___________________________________________________
___________________________________________________________________________________________________________
EXPECTED DURATION OF ADMINISTRATION: __________________________________________________________________
CAN REACTION BE EXPECTED
Yes No If yes, please describe: _____________________________________
If any change, please advise in writing immediately.
_______________________________________________________ __________________________________________________
PHYSICIANS SIGNATURE ADDRESS
_______________________________________________ ________________________________ _______________________
PLEASE PRINT NAME TELEPHONE NO. DATE
__________________________________________________ _____________________________________________
SCHOOL NURSE DCPS TRAINED STAFF
CSS1301A Revised: 3/07
District of Columbia Medication and Treatment Authorization Form
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