507.2E1 - Authorization - Asthma or Other Airway Constricting Disease Medication or Epinephrine Auto-Injector Self-Administration Consent

AUTHORIZATION- ASTHMA, AIRWAY CONSTRICTING, OR RESPIRATORY DISTRESS MEDICATION SELF-ADMINISTRATION CONSENT FORM

_____________________________       ___/___/___     _________________     ___/___/___

Student's Name (Last), (First)  (Middle)     Birthday                    School                    Date

In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency. The following must occur for a student to self-administer asthma medication, bronchodilator canisters or spacers,      other airway constricting disease medication or      to self-administer an epinephrine auto-injector:

• Parent/guardian provides signed, dated authorization for student medication self-administration.
• Parent/guardian provides a written statement from the student’s licensed health care professional (A person licensed under chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under chapter 152 or 152E and registered with the board of nursing, or a physician assistant licensed to practice under the supervision of a physician as authorized in chapters 147 and 148C) containing the following:
  
  • Name and purpose of the medication,
  • Prescribed dosage, and
  • Times or special circumstances under which the prescribed medication      is to be administered.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.
• Authorization shall be renewed annually.  In addition, if any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.

Provided the above requirements are fulfilled, the school shall permit the self-administration of the prescribed medication by a student      while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before-school or after-school care on school-operated property. If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

Pursuant to state law, the school district or and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine  auto-injector by the student as provided by law.