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District of Columbia Medication and Treatment Authorization Form

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District of Columbia Medication and Treatment Authorization Form Page 2
District of Columbia Medication and Treatment Authorization Form
GOVERNMENT OF THE DISTRICT OF COLU BIA M
DEPARTMENT OF HEALTH
School Health Program
AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
Dear Parent/Guardian and Physician:
We discourage the administration of medication in the school setting and request that whenever
possible medications are scheduled during non-school hours. If medication is needed while in
school, the following requirements must be met on the first day that the student is to receive
medication:
1. No medication will be administered without the parent’s/guardian’ signed consent and
the physician’s written medication authorization order. This will be kept on file in the
Student’s Health Record. The parent/guardian is responsible for obtaining the required
information from the physician.
2. A separate parent/guardian consent form and physician’s medication authorization order
must be on file for each medication a student is to receive at school.
3. The medication must be properly labeled by the pharmacist. The label must include:
a.) Name of student’s name, b.) Name of medication, c.) Date, d.) Dosage and time of
administration, and e.) Directions for administration.
4. The first day’s dosage of any new medication must be given at home.
5. All medications must be brought to school be the parent/guardian and given to
authorized personnel.
6. The parent/guardian is responsible for submitting to the school, in writing from the
physician, notification of any change in dosage or time of administration.
7. All medication kept in school will be stored in a secure area accessible only to authorized
administering personnel. (Such storage will be at the risk of the parent/guardian). The
school nurse nor District of Columbia Public Schools (DCPS) personnel will assume any
responsible for possible loss of students’ medication.
8. One week after expiration of the physician’s order, the unused portion of the medication
must be collected by the parent/guardian or it will be destroyed.
9. DCPS personnel nor the school nurse will assume any responsibility for non-medically
prescribed medication or medication self-administered by the student.
10. Parents/guardians must let DCPS and the school nurse know in writing if a student is
Lactose-intolerant.
CSS 1301A Revised: 3/07
District of Columbia Medication and Treatment Authorization Form