_____________________________                 ___/___/___                _________________                 ___/___/___
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 If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the  school or discipline may be imposed, after notification is provided to the student’s parent.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.

 

 

_______________________                 _______________          _______________________________    _____________
Medication                                                            Dosage                                           Route                                                         Time

 

_________________________________________________________________________________________________
Purpose of Medication & Administration /Instructions

 

_____________________________________________________          __________/___________/_______________
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 medication,  bronchodilators canisters or spacers, or other airway constricting disease medication(s) and/or an  epinephrine auto-injector at school and in school 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 an epinephrine auto-injector or for supervising,  monitoring, or interfering with a student's self-administration of medication or use of an  epinephrine auto-injector. I acknowledge that the school district is to incur no liability, except for  gross negligence, as a result of self-administration of medication or use of an epinephrine auto injector by the student.

• 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  Educational Rights and Privacy Act (FERPA) and any other applicable laws. 

• 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

 

                                                                                                        ______________________________________
                                                                                                                                                        Business Phone

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

Self-Administration Authorization Additional Information

 

Approved by the North Tama Board of Education on 9-20-2021
Approved by the North Tama Board of Education on 8-15-2022
Approved by the North Tama Board on 7/17/2023.

 

_________________________________            ___/___/___      _________________                 ___/___/___
Student's Name (Last), (First), (Middle)                  Birthday               School                                                   Date

 

School medications and special health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide  special health services listed. Electronic signatures meet the requirement of written signatures. • The prescribed medication is in the original, labeled container as dispensed. 
• The prescription medication label contains the student’s name, name of the medication, the medication  dosage, time(s) to administer, route to administer, and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that  changes are necessary.

 

______________________________                  ____________              _________________     ____________
Prescribed Medication                                                    Dosage                                   Route                            Time at School

 

Special Health Services and instructions, in indicated:

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 

_____/_____/______
Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services Listed

 

______________________________________________________________            _____/_____/______
Prescriber’s Signature                                                                                                                          Date

And credentials (when indicated for health service delivery)

 

__________________________________________________                             __________________________
Parent/Guardian Signature                                                                                                               Date

 

__________________________________________________                            __________________________
Parent/Guardian address                                                                                                             Home Phone

                                               

Additional Information                                                                          Business Phone

 

__________________________________________________________________________________________

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

Authorization Form

 

 

 

I.C. Iowa Code                                      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           Description
281 I.A.C. 14                                        Special Health Services
281. I.A.C 14.1                                     Medication Administration
481. I.A.C. 620                                     Nursing Practice for Registered Nurses/LPNs

Cross References:  603.03  Special Education
                                         607.02  Student Health Services
                                         607.02-R(1)  Student Health Services - Regulation
                                         804.05  Stock Prescription Medication Supply
                                         804.05-E(1)  Stock Prescription Medication Supply - Parental Authorization and Release Form for the Administration of a Voluntary School Supply of Stock Medication for Life Threatening Incidents

Approved: 9/20/2021, 7/17/2023, 3/25/2026
Reviewed: 2/25/2026
Revised: 2/25/2026

 

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

 

 

Approved by the North Tama Board on 7/17/2023.

 

_________________________________           ___/___/___     ______________           ___/___/___

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

 

The district supplies the following nonprescription, over-the-counter medications that are listed

below. Generic brands may be substituted, (select all that apply):

 

• Acetaminophen administered per manufacturer label
• Throat Lozenges administered per manufacturer label
• Other: ____________________ administered per manufacturer label (Please Specify)
• Other: ____________________ administered per manufacturer label (Please Specify)
• Other: ____________________ administered per manufacturer label (Please Specify)
• Other: ____________________ administered per manufacturer label (Please Specify)

 

Voluntary school stock of nonprescription, over-the-counter medications are administered following these guidelines:

 

• Parent has provided a signed, dated annual authorization to administer of the nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature.
• The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.
• All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the counter medication.
• Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOT applicable.
• Nonprescription, over-the-counter medications approved by the Federal Drug Administration that require emergency medical service (EMS) notification after administration are NOT applicable.
• Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the department and annual medication administration procedural skills check.
  • o Districts stocking the administration of a voluntary stock of nonprescription, over-the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:
• when to contact the parent when a nonprescription medication, over the counter medication is administered;
• documentation of the administration of the nonprescription, over-the-counter medication and parent contact;
• a limit to the administration of a school’s stock nonprescription, over-the-counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school Year;
• the development of an individual health plan for ongoing medication administration or health service delivery at school.

I request that the above-named student receive the voluntary stock nonprescription, over-the-counter medications supplied by the school in accordance with the district guidelines and protocol.

 

__________________________________________      _________________________
Parent Signature                                                                      Date

__________________________________________     _________________________
Parent/Guardian Address                                                         Home Phone

 

 

Approved by the North Tama Board on 7/17/2023.