Note: Sample medication logs can be found in Chapter 5 of the Texas Department of State Health Services Texas Guide to School Health Programs at http://www.dshs.state.tx.us/schoolhealth/shpguide/chap5.pdf.

Exhibit A—Request for the Administration of Medication at School

Date form was received by the school:________________

Student name: ______________________________Date of birth or age: ___________

Grade: ______Teacher/Classroom: ________________

Name of medication: ________________________________________________

Reason for medication: ________________________________________________

Form of medication/treatment:

? Tablet/capsule? Liquid? Inhaler? Injection? Nebulizer

? Other ________________________________

Instructions: (Schedule and dose to be given at school): ________________ _________________________________________________________________________

Start: ? Date form received? Other date: ________________

Stop: ? End of school year? Other date: ________________

Restrictions and/or important side effects:

?None Anticipated

?Yes. Please describe: _____________________________________________________________________________________________________________________

Special storage instructions:

? None? Refrigerate? Other: ________________

Physician Information:

Name: __________________________________________________

Address: ________________________________________________

Phone Number: ________________________________

Physician Signature____________________________________________ Date ________

To be completed by parent/guardian:

I give permission for ________________________________ (name of child) to receive the above medication at school in accordance with Department policy [See FFAC]

Parent/Guardian Signature _________________________________________ Date ______

[Developed using resources from the American Academy of Pediatrics and Texas Department of State Health Services]

Exhibit B—Authorization to Secure Emergency Medical Treatment of a Student

Name of student ________________________________________ Grade __________

Date of birth _____________/___________/_____________

Parents' names _________________________________________________________

Work phone ______________________ Home phone _________________________

Work phone ______________________ Home phone _________________________

Address ______________________________________________________________

Friend or relative who may know where to locate a parent

Name ________________________________________________________________

Phone ________________________________________________________________

Student's physician or other preferred health-care provider

Name ________________________________________________________________

Phone ________________________________________________________________

Student's dentist

Name ________________________________________________________________

Phone ________________________________________________________________

Medications or drugs to which the student has had an allergic or adverse reaction:

I hereby authorize the Superintendent of ____________________________ SD or a designated representative to secure any and all emergency medical care and treatment for ________________________ (student's name) for acute illness suffered or injury sustained while at school or participating in school-related activities. I prefer that emergency treatment be secured at _______________________________ (indicate preferred medical facility); the Department may use another licensed hospital, clinic, or medical facility, if necessary, with the following exceptions: _______________________________________________.

I understand that cost of services provided by ambulance, private physician, clinic, hospital, or dentist remains the responsibility of the parent or guardian and will not be assumed by the Department or any of its officers or employees.

I ? do not have ? do have medical insurance coverage on my child with __________________________________________________ Insurance Company.

Parent's signature __________________________________________Date ___________

Copies of this authorization may be presented to the admissions office of a hospital or clinic or to a physician or dentist. Other distribution will occur only within the limitations of the Family Educational Rights and Privacy Act.

Exhibit C—Authorization for Self-Administration of Asthma and/or Anaphylaxis Medication

Name of student Grade

Name of parent

Parent's contact information

Prescribing health-care provider

Contact information for the prescribing health-care provider

Description of condition/reason for medication

Prescribed medication and dosage

How/when the medication should be used at school (dosage, method, times)

Anticipated length of treatment

Possible adverse reaction

_____________________________________ (student's name) has asthma and/or anaphylaxis and is treated with prescription medication. (He)(She) is capable of administering (his)(her) own medication at school and at school-related or school-sponsored activities. The Department will be informed of any changes to the medication specified on this form, to the dosage, or to the recommended regimen by an updated version of this consent form.

Parent Date

Health-care provider Date

Harris County Department of Education



DATE ISSUED: 09/09/2021