507.02 E3 - Parental Authorization and Release Form for Independent Self Carry and Administration of Prescribed Medication or Independent Delivery of Health Services by the Student

507.02 E(3): PARENTAL AUTHORIZATION AND RELEASE FORM FOR INDEPENDENT SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE STUDENT

 

_________________________________ ___/___/___ _________________ ___/___/___

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

 

I request the above-named student (Parent/Guardian initial all that apply)

 

______ Carry and complete co-administration of prescribed medication, when competency has been

demonstrated to licensed health personnel working under the auspices of the school. 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 professionals regardless of competency. The

information provided by the parent for medication administration is confidential as provided by the Family

Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of

the medication to and from school and to pick up remaining medication at the end of the school year or when

medication is expired. If the students 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withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

 

______________________________________________________________________________________

Prescribed Medication Dosage Route Time at School

 

______ Co-administer, participate in planning, management and implementation of special health services at

school and school activities after demonstration of proficiency to licensed health personnel working under the

auspices of the school. The information provided by the parent for health service delivery is confidential as

provide by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to

coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to

provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year.

 

Special Health Services Delivery:

________________________________________________________________________________________________________________________________________________________________________________

 

Procedures for abandoned medication disposal shall be in accordance with applicable laws.

 

____________________________________ ___/___/___

Prescriber’s Signature Date

and credentials (when indicated for health service delivery)

 

____________________________________ ___/___/___

Parent/Guardian Signature Date

 

_______________________________________ __________________________

Parent/Guardian Address Home Phone

 

I.C. Iowa Code References Description

Iowa Code § 124 Controlled Substances 

Iowa Code § 147.107 Drug Dispensing/Supplying 

Iowa Code § 152 Nursing 

Iowa Code § 155A.4 Dispensing/Distributing Prescription Drugs - Exceptions 

Iowa Code § 280.16 Asthma - epi-pens 

Iowa Code § 280.23 Student Health Services  

 

I.A.C. Iowa Administrative Code

281 I.A.C. 14 Special Health Services 

281. I.A.C 14.1 Medication Administration - 

655 I.A.C 6 Nursing 

 

Approved: October 16, 2023

Reviewed: October 16, 2023

Revised: October 16, 2023