ORRVILLE CITY SCHOOLS



CLOVERLEAF LOCALSCHOOLS

PRESCRIPTION & OVER-THE-COUNTER MEDICATION FORM

Medication Administration by School Employees (O.R.C. 3313.713)

If you want your child to receive ANY medication, Ohio law requires written permission from your health care provider and parent. This includes all prescriptions and/or over the counter medications (including holistic).

* DO NOT USE THIS FORM FOR ASTHMA, ALLERGY OR SEIZURE MEDICATIONS (see required health care plan)

_________________________________ _________________ CHS CMS CES _______________________________

Student Name DOB School Grade and Year

____________________________________________________________________ _______________________________

Name of Medication/ Dosage/Route to be administered Time of administration

______________________________________________ ____________________________________________________

Date administration to begin and to end Adverse reaction to report to physician

______________________________________________ ____________________________________________________

Parent’s phone number for emergency contact Any special instructions for medication administration

_________________________________________________________________________ ______________________

Print Name of Physician Phone Date

Signature of Physician __________________________________________________________________

(ALL MEDICATION MUST HAVE PHYSICIAN SIGNATURE)

Medication Administration Policy for Cloverleaf Local Schools

Students needing medication are encouraged to receive the medication at home, if possible. If this is not possible, it is done in compliance with the following:

1. In accordance with Ohio Nursing Law, the RN does not delegate the dispensing of medication to any unlicensed personnel.

2. The school nurse or person (s) approved do not dispense medication for the treatment of fever.

3. Prior to dispensing ANY TYPE OF MEDICATION (prescription, over-the-counter, holistic) written permission must be

received from the parent(s) of the student and Ohio authorized prescriber indicating the exact dispensing instructions.

4. This Medication Form must be completed for each school year regardless of life-long medication usage.

5. A new Medication Form must be completed & signed when there is a change in any of the information originally provided by

the Ohio authorized prescriber (i.e. dosage, dispensing).

6. EACH MEDICATION must have their own Medication Form. Medication cannot be combined on the same form.

7. All non- prescription medications MUST be in a new unopened bottle.

8 The medication must be received from an adult in the original dispensing container. The label on the prescription

container must state the child’s name and current dispensing instructions. Any medication tablets that must be split needs to be

done prior to the school receiving the medication. Please ask the pharmacy for an extra labeled bottle if needed for home & school

9. The school nurse or authorized trained designee has the right to refuse the dispensing of any medication based on questionable

dosage, procedure and/or drug interactions. The student’s physician may be contacted to verify dispensing of any medication.

I hereby request and give my permission to the principal, nurse or designee to administer the medication listed above to my child as instructed by physician. I specifically agree that if any information on the attached Medication Administration statement changes, I will immediately submit to the school nurse or building principal a new medication form completed and signed by parent and authorized prescriber. Any authorized school employee administering the medication described on this statement of medication administration shall be entitled to rely upon the information therein contained until such time as a new form is submitted. The medication will be kept secure/locked in the school as directed.

_________________________________ __________________ ___________________________

Parent/Guardian Signature Date School RN reviewed/Date

High School Middle School Elementary School

Office: 330-302-0328 Office: 330-302-0207 Office: 330-302-0103

Fax: 330-302-0530 Fax: 330-302-0520 Fax: 330-302-0080

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Student Photo ID

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