________________________________ __________ _______________ ____/____/____
Student’s Name (Last), (First), (Middle) Birthday School Date
In order for a student to self-administer medication for asthma or any airway constricting disease:
- Parent/guardian provides signed, dated authorization for student medication self-administration.
- Physician (person licensed under chapter 148, 150, or 150A, physician, physician’s assistant, advanced registered nurse practitioner, or other person licensed or registered to distribute or dispense a prescription drug or device in the course of professional practice in Iowa in accordance with section 147.107, or a person licensed by another state in a health field in which, under Iowa law, licensees in this state may legally prescribe drugs) provides written authorization containing:
- purpose of the medication,
- prescribed dosage,
- times, or;
- special circumstances under which the 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 is renewed annually. 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, a student with asthma or other airway constricting disease may possess and use the student’s medication 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 If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed.
Pursuant to state law, the school district or accredited nonpublic school and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district or nonpublic school is to incur no liability, except for gross negligence, as a result of self-administration of medication by the student as established by Iowa law.
____________________ ______________ ________________ ________________
Medication Dosage Route Time
Purpose of Medication & Administration/Instructions: __________________________________
______________________________________________________________________________
AUTHORIZATION – ASTHMA OR AIRWAY CONSTRICTING MEDICATION SELF-ADMINISTRATION CONSENT FORM
___________________________________ __________________________________
Special Circumstances Discontinue/Re-Evaluate/Follow-up Date
___________________________________ _____/_____/_____
Prescriber’s Signature Date
___________________________________ __________________________________
Prescriber’s Address Emergency Phone
I request the above-named student possess and self-administer asthma or other airway constricting disease medication(s) at school and activities according to the authorization and instructions.
I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or for supervising, monitoring, or interfering with a student’s self-administration of medicine.
I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.
I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.
I agree the information is shared with school personnel in accordance with the Family Education Rights and Privacy ACT (FERPA).
I agree to provide the school with back-up medication approved in this form.
(Student maintains self-administration record).)
_________________________________ _____/_____/_____
Parent/Guardian Signature Date (agreed to above statement)
_________________________________ ________________
Parent/Guardian Address
Home Phone _________________________
Cell/Work Phone______________________
Self-Administration Authorization Additional Information
(January 17, 2005; March 21, 2011; January 19, 2015; August 19, 2019)