FFAC(EXHIBIT) - WELLNESS AND HEALTH SERVICES: MEDICAL TREATMENT

See the following pages regarding administering medication and emergency health care to students:

EXHIBIT A

SPRING INDEPENDENT SCHOOL DISTRICTREQUEST FOR ADMINISTRATION OF MEDICATION

This form must accompany each medication to be administered, whether prescription or nonprescription medication. Additional copies of this form are available in the nurse's office or copies may be made of this sheet.

To: Principal, (school name)

Date:

As parent/guardian of ______________________________, a student in the _____ grade, I (print parent's name) ______________________________, give permission for Spring Independent School District to administer to my child, the following medication:

Name of medication:

Color: Dose (amount) to be administered:

Time to be administered:

Date to discontinue:

Additional instructions or side effects regarding the above medication:

Reason for administering medication:

Student's physician name:

Telephone Number: (____)

Prescription medication must be in the original container with the student's name, the doctor's name, and a current date. It will be given according to the instructions on the label. Nonprescription medication must be in the original container and will be given according to directions.

Medication for students in elementary schools must be brought to the school by the parent. Medication may not be transported by elementary students on the bus.

School clinic staff is authorized to contact and consult with your child's physician regarding the child's medical needs.

The District, the Board, and the staff shall be immune from civil liability for damages or injuries resulting from the administration of medication to a student.

Parent/Guardian Signature

Work Phone: (____) Home Phone: (____)

Physician's Signature (if required*)

Date

* Required annually in treatment of long-term medication administration as in asthma, diabetes, chronic infections, Attention Deficit Disorder, controlled medicines, and over-the-counter medicines given daily for more than two weeks.

EXHIBIT B

SPRING INDEPENDENT SCHOOL DISTRICTREQUEST FOR ATHLETIC TRAINER TO ADMINISTER MEDICATION

To: Principal, ______________________________ (school name)

Date: _________________________

I, ______________________________ (name), am the parent/guardian of ______________________________ (student's name), a student in the (grade) _____ level. I request that an athletic trainer employed by the Spring Independent School District give my child the following medication(s) as needed:

NONPRESCRIPTION MEDICATIONS

Check the nonprescription medication(s) below that you request to be administered to your child by the athletic trainer on an "as needed" basis:

PRESCRIPTION MEDICATION

I request that the following, ___________________________________ (name of prescription medicine), be administered to my child, ______________________________, when prescribed by a physician.

Prescription medication must be in the original container with the student's name, the doctor's name, and a current date. It will be given according to the instructions on the label.

Name of prescription medication:

Color: Dose (amount) to be administered:

Time(s) to be administered:

Additional instruction or side effects regarding any of the above medication(s):

Student's Personal Physician's Name

Telephone Number

The District, the Board, and the staff shall be immune from civil liability for damages or injuries resulting from the administration of medication to a student.

I give permission for my child, ______________________________ (Student's Name), to receive medication as instructed on this form.

Parent/Guardian Signature ____________________________________________________

Work Phone: (___) Home Phone: (___)

Date _________________________

EXHIBIT C

SPRING INDEPENDENT SCHOOL DISTRICTGUIDELINES FOR PHYSICAL EXAMINATION OF STUDENT

The guidelines are:

Nurses, health aides, and other appropriate school personnel may perform only those physical examinations necessary to respond to immediate health needs.

A nurse, health aide, or other appropriate school personnel may determine that it is necessary to roll up a shirt sleeve or pant leg, remove a jacket or shirt, or loosen or remove pants in order to adequately examine the student.

Except as otherwise provided in this guideline, undergarments may be removed from a student only if a nurse, health aide, or other school personnel determines a medical necessity exists, including suspected abuse. When such a determination is made, under-garments may be removed from a student only if another adult of the same gender as the student is present.

In an emergency situation, school personnel may remove a student's undergarments without the presence of another adult of the same gender as the student if immediate action regarding the student's health is required.

School personnel may remove a student's undergarments without the presence of another adult of the same gender if the school personnel is changing diapers, assisting with toileting, or cleaning a child after a toileting accident.

EXHIBIT D

SPRING INDEPENDENT SCHOOL DISTRICT

Distrito Escolar Independiente de Spring

16717 ELLA BOULEVARD * HOUSTON, TEXAS 77090 (281) 586-1100

FORM FOR SELF-ADMINISTRATION OF PRESCRIPTION ASTHMA MEDICATION

Forma De Auto-Administración De Medicina Formulada Para El Asma

Student name (Nombre del estudiante)

In grade (En grado) ____________ has asthma and is capable of self-medication. (tiene asma y es capacitado para administrarse la medicina.)

Physician signature (Firma del doctor)

Phone number (Teléfono)

Name of medication (Nombre de la medicina)

Dosage (Dosis)

Time of administration (Horas para aplicarta)

Date to discontinue (Fecha para descontinuaría)

Purpose for administering medication (Propósito de la aplicación de la medicina)

Medication must be dispensed following the Spring Independent School District's medication policy. This form must be completed in addition to the routine District medication authorization form. (La medicina debe administrarse siguiendo las reglas del Distrito Escolar Independiente de Spring. Está forma se debe completar en adición con la forma rutinaria del distrito para la autorización de los medicamentos.)

Responsibility For Carrying Prescription Asthma Medication (Responsabilidades Para Llevar Medicina Formulada Para El Asma):

Yes/Si

No

?

?

Asthma Care Plan Returned (Regreso la forma del Plan de cuidados para del Asma)

?

?

Correct use of prescription asthma medication use observed by nurse. (Uso correcto del medicina formulada para Asma observado por la enfermera.)

?

?

Proper timing for prescription asthma medication use observed by nurse. (Tiempo apropiado con el uso del la formulada medicina para Asma observado por la enfermera.)

?

?

Not sharing prescription asthma medication with other students. (No compartir la Formulada Medicina para Asma con otros estudiantes.)

?

?

Keep prescription asthma medication in student's belongings. (Mantener la Formulada Medicina para Asma con las pertenencias del estudiante.)

?

?

Provides a second prescription asthma medication to be kept in the health clinic. (Proveer un segundo Formulada Medicina para Asma y mantenerlo en la Clínica de Salud.)

?

?

Properly labeled prescription on immediate prescription asthma medication. If the container is too small for a full label, it must be labeled with student name and prescription number with the full label on the outer box or container. (Apropiada etiqueta con la medicina, es decir, la formulada medicina para Asma. Si el envase es muy pequeño para la escritura en la etiqueta completa, entonces debe estar marcada con el nombre del estudiante y el número de la receta y la etiqueta completa por fuera de la caja de la medicina.)

?

?

Agrees to come directly to the health clinic if the student continues to have difficulty with breathing, wheezing, or is experiencing chest tightness after using the prescription asthma medication. (El estudiante está de acuerdo de ir directa-mente a la clínica si tiene constante dificulta de respirar, resollar, o si esperimenta apretamiento de pecho después de haber usado la formulada medicina para Asma.)

The student [does] [does not] demonstrate meeting the above specified responsibilities. The privilege of carrying the prescription asthma medication [will] [will not] be allowed.

El estudiante [si] [no] demuestra que cumple las responsabilidades especificadas en la parte de arriba. El privilegio de llevar la formulada medicina para asma [se le permite] [no se le permite].

Student Signature (Firma del Estudiante[a]):

Date (Fecha):

RN Signature (Firma de Enfermero[a] Registrada):

Date (Fecha):

Principal Signature (Firma del Principal):

Date (Fecha):

My child will be responsible for carrying this prescription asthma medication and will self-administer. My child agrees to follow the District's procedures concerning the handling and administration of this medication. I understand that school personnel are unable to monitor the frequency or method or usage of prescription asthma medication when it is carried by the student.

Será la responsabilidad de mi hijo(a) para llevar la formulada medicina para asma y administrársela. Mi hijo(a) está de acuerdo en seguir los procedimientos del distrito referentes a la dirección y administración de este medicina. Entiendo que el personal de la escuela es incapaz de controlar la frecuencia o el método o uso de la formulada medicina para asma cuando el estudiante la tiene.

Parent/Guardian Signature (Firma de los Padres/Guardián):

Date (Fecha):

Spring ISD

FFAC(EXHIBIT)-X

LDU-11-02

DATE ISSUED: 3/18/2002