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