OOE Policy #11



OOE Policy #11

Attachment 10

DEPARTMENT OF CHILDREN AND FAMILIES (DCF)

OFFICE OF EDUCATION

DCF REGIONAL SCHOOLS

SELF-ADMINISTRATION OF MEDICATION BY STUDENT

A student’s parent/guardian/residential provider may request that the student be allowed to carry and self-administer his/her own medication in school. The self-administration of medication by a student for asthma or other potentially life-threatening illnesses or for a life-threatening allergic reaction shall be reviewed, evaluated and approved on a case-by-case basis by the Education Supervisor (ES); the school’s nurse; the parent/ guardian; the residential provider, as appropriate; the health-care provider; and the student.

1. The student’s parent/guardian shall provide the school with written authorization for the student to carry and self-administer medication in school by completing and submitting to the school the “Parent/Guardian Authorization” form (Attachment 10A).

a. On the form, the parent/guardian is also indicating whether or not the student has been instructed in and has demonstrated the proper technique for the self-administration of his/her medication.

b. When submitting the form, the parent/guardian/residential provider shall supply the school with a prescription from the student’s health-care provider for each medication.

2. The student’s parent/guardian/residential provider shall request the student’s health-care provider to complete the “Health-Care Provider Certification” form (Attachment 10B) and shall then submit the finished form to the school. On this form, the health-care provider is certifying that it is medically appropriate for the student to self-administer the prescribed medication in school and that the student:

a. has a potentially life-threatening illness or allergy;

b. is capable of self-administering medication;

c. has been instructed in the proper method of the self-administration of the prescribed medication; and

d. has demonstrated competence in the appropriate technique for self-administrating his/her medication.

3. The written authorization from the student’s parent/guardian, and the written certification from the student’s health-care provider shall be filed in the student’s health record.

4. The school’s nurse shall review the appropriate Student Agreement form (Attachment 10C or 10D) with each student who is a candidate for self-administering medication in school.

a. If the student meets the criteria on the form, the student and the school’s nurse shall sign and date the document.

b. If the student does not meet the criteria on the form, the student’s ability to self-administer medication shall be reviewed by the ES, the school’s nurse, the student’s health-care provider, the student’s parent/guardian, and the residential provider, as appropriate.

c. The Student Agreement Form will need to be modified collaboratively with the OOE Nurse Consultant for students who will self-administer medication for illnesses other than asthma or allergy/anaphylaxis.

5. A student who is permitted to self-administer medication in school shall be permitted to carry an inhaler or other approved medication at all times.

6. If the student is not approved to self-administer medication in school, the student shall receive his/her medication in accordance with the nursing procedures for the Administration of Medication.

7. The ES or the school’s nurse shall inform the student that he/she is responsible for immediately notifying a staff person/the school’s nurse after he/she self-administers a medication.

a. A staff person who has been so notified by a student and/or who has witnessed the self-administration of medication by a student shall immediately inform the school’s nurse.

b. The school’s nurse shall monitor the student, as appropriate.

c. When a student self-administers epinephrine for a life-threatening allergic reaction, staff shall call 9-1-1, even if the student’s symptoms appear to have resolved.

8. The permission for a student to self-administer a medication in school shall be effective for one year from the date of the signed authorization from the parent/guardian or the signed certification from the health-care provider, whichever date expires first.

9. If a student, who is carrying and self-administering medication in school, misuses or abuses the medication, exceeds the prescribed dosage, or endangers others with the medication:

a. the approval for the student to self-administer medication shall be immediately withdrawn, which may include confiscating the medication, as necessary;

b. the ES shall notify the student’s parent/guardian/residential provider as soon as possible about the misuse of the medication; and

c. the student’s behavior shall be evaluated by the parent/guardian; the residential provider, as appropriate; the ES; the school’s nurse; and the student’s health-care provider to determine the necessary corrective actions which may include discontinuation of the student’s self-administration of medication in school.

10. If at any point, a student is no longer approved to self-administer medication, the student shall not return to school until the parent/guardian/residential provider provides the school with a prescription for the medication, the actual medication in a properly labeled bottle, and a “Permission for In-School Medication/Treatment by School’s Nurse” form signed by the parent/guardian.

OOE Policy #11

Attachment 10A

DEPARTMENT OF CHILDREN AND FAMILIES (DCF)

OFFICE OF EDUCATION

DCF Regional School, ___________________ Campus

PERMISSION FOR STUDENT TO SELF-ADMINISTER

MEDICATION IN SCHOOL FOR A POTENTIALLY

LIFE-THREATENING ILLNESS

PARENT/GUARDIAN AUTHORIZATION

Student’s Name:______________________________ DOB:___________________

I give my permission for the above-named student to carry and self-administer ___________________________ in school.

Name of Medication

This medication is for the treatment of _____________________________________.

He/She has / has not (circle one) been instructed in the proper technique for the self-administration of the above-named medication.

He/She has / has not (circle one) demonstrated the ability to self-administer this medication appropriately.

I will supply a prescription from the above-named student’s health-care provider for each medication. I understand the prescription(s) and this permission form are valid for one calendar year unless otherwise specified.

This student and I understand there are serious consequences for the misuse of any medications.

____________________________________ _______________________________

Printed Name of Person Completing Form Signature of Person Completing Form

____________________________________ _______________________________

Relationship to Student Date

OOE Policy #11

Attachment 10B

DEPARTMENT OF CHILDREN AND FAMILIES (DCF)

OFFICE OF EDUCATION

DCF Regional School, ___________________ Campus

PERMISSION FOR STUDENT TO SELF-ADMINISTER

MEDICATION IN SCHOOL FOR A POTENTIALLY

LIFE-THREATENING ILLNESS OR ALLERGY

HEALTH-CARE PROVIDER CERTIFICATION

Student’s Name:______________________________ DOB:________________

The above-named student is under my care. It is medically appropriate for this student to self-administer the following prescribed medication in school:

Name of Medication:_________________________________

Dosage:___________________________________________

This medication is for the treatment of ______________________________________.

This student has / has not (circle one) been instructed in the proper technique for the self-administration of the above-named medication.

This student has / has not (circle one) demonstrated the ability to self-administer this medication appropriately.

I understand the prescription for this medication and this permission form are valid for one calendar year unless otherwise specified.

_____________________________________ ______________________________

Printed Name of Health-Care Provider Signature of Health-Care Provider

____________________________________ _______________________________

Telephone Number Date

OOE Policy #11

Attachment 10C

DEPARTMENT OF CHILDREN AND FAMILIES (DCF)

OFFICE OF EDUCATION

DCF Regional School, ___________________ Campus

SELF-ADMINISTRATION OF MEDICATION FOR ASTHMA

STUDENT AGREEMENT

Student’s Name:_______________________________ DOB:__________________

Medication:___________________________________ Date:__________________

I agree to:

• Follow my prescribing health-care provider’s medication orders.

• Use the correct medication administration techniques.

• Notify a teacher/school’s nurse immediately when I use medication at school.

• Not allow anyone else to use my medication under any circumstances.

• Keep a supply of my medication with me in school and on field trips.

• Notify the school’s nurse if the following occurs:

➢ My symptoms continue or get worse after taking the medication.

➢ My symptoms reoccur within 2-3 hours after taking the medication.

➢ I think I might be experiencing side effects from my medication.

➢ Other_________________________________________________________

• I understand that permission for self-administration of medication may be discontinued if I do not follow the safeguards established above.

___________________________________ __________________________

Signature of Student Date

____ Verbalizes Name of Medication

____ Verbalizes Dose

____ Verbalizes Symptoms of Life-Threatening Illness/Allergic Reaction

____ Demonstrates Proper Technique for Inhaler Medication

• removes cap and shakes if applicable

• attaches spacer if applicable

• breathes out slowly

• presses down inhaler to release medication

• breathes in slowly

• holds breath for 10 seconds

• repeats as directed.

____ Verbalizes Safe Use of Medication

This student has demonstrated knowledge about and proper use of his/her medication.

___________________________________ __________________________

Signature of School’s Nurse Date

OOE Policy #11

Attachment 10D

DEPARTMENT OF CHILDREN AND FAMILIES (DCF)

OFFICE OF EDUCATION

DCF Regional School, ___________________ Campus

SELF-ADMINISTRATION OF MEDICATION FOR ALLERGY/ANAPHYLAXIS

STUDENT AGREEMENT

Student’s Name:_______________________________ DOB:__________________

Medication:___________________________________ Date:__________________

I agree to:

• Follow my prescribing health-care provider’s medication orders.

• Use the correct medication administration techniques.

• Notify a teacher/school’s nurse immediately when I use medication at school.

• Not allow anyone else to use my medication under any circumstances.

• Keep a supply of my medication with me in school and on field trips.

• Notify the school’s nurse if the following occurs:

➢ My symptoms continue or get worse after taking the medication.

➢ My symptoms reoccur within 2-3 hours after taking the medication.

➢ I think I might be experiencing side effects from my medication.

➢ Other_________________________________________________________

• I understand that permission for self-administration of medication may be discontinued if I do not follow the safeguards established above.

___________________________________ __________________________

Signature of Student Date

____Verbalizes Name of Medication

____Verbalizes Dose

____Verbalizes Symptoms of Life-Threatening Illness/Allergic Reaction

____Demonstrates Proper Technique for Epinephrine Via Pre-filled Auto-Injector Mechanism

• removes safety cap from injector

• places auto-injector against lateral aspect of thigh

• pushes auto-injector firmly against thigh until injector activates

• holds for a minimum of ten (10) seconds

• disposes injector properly

• notifies school’s nurse or school administrator of event

• takes oral antihistamine, if prescribed

____ Verbalizes Safe Use of Medication

This student has demonstrated knowledge about and proper use of his/her medication.

___________________________________ __________________________

Signature of School’s Nurse Date

OOE Policy #11

Attachment 10E

DEPARTMENT OF CHILDREN AND FAMILIES (DCF)

OFFICE OF EDUCATION

DCF Regional School, ___________________ Campus

SELF-ADMINISTRATION OF MEDICATION FOR DIABETES CARE

STUDENT AGREEMENT

NOTE: This student’s health care provider has indicated student is able to safely self- test and/or self-medicate (see Attachment 6B)

Student’s Name:_______________________________ DOB:__________________

Medication:___________________________________ Date:__________________

I agree to:

• Follow my prescribing health-care provider’s testing and medication orders.

• Use the correct testing and medication administration techniques.

• Notify a teacher/school’s nurse immediately should I develop symptoms requiring intervention.

• Notify a teacher/school’s nurse immediately when I use medication at school.

• Not allow anyone else to use my medication under any circumstances.

• Keep a supply of my medication with me in school and on field trips.

• Notify the school’s nurse if the following occurs:

➢ My symptoms continue or get worse after taking the medication.

➢ I think I might be experiencing side effects from my medication.

➢ Other_________________________________________________________

• I understand that permission for self-administration of medication may be discontinued if I do not follow the safeguards established above.

___________________________________ __________________________

Signature of Student Date

____Verbalizes name of medication(s) and/or treatment methods used

____Verbalizes medication dosage

____Verbalizes prescribed insulin dose

____Verbalizes safe use of medication

____Verbalizes symptoms of hypoglycemia and hyperglycemia

____Demonstrates proper technique for delivery of insulin

✓ Aseptic technique utilized

✓ Correct dose of insulin drawn into syringe

✓ Proper self-injection technique utilized

✓ Disposes syringe properly

____Demonstrates proper technique when self-testing blood glucose

____Demonstrates the ability to properly operate insulin pump

This student has demonstrated knowledge about and proper use of his/her medication.

___________________________________ __________________________

Signature of School’s Nurse Date

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