507.02 - Administration of Medication to Students

The board is committed to the inclusion of all students in the education program and recognizes that some students may need prescription and nonprescription medication to participate in their educational program.

Medication shall be administered when the student's parent or guardian provides a signed and dated written statement requesting medication administration and the medication is in the original, labeled container, either as dispensed or in the manufacturer's container. Administration of medication may also occur consistent with board policy 804.8 Stock Medication for Life Threatening Incidents.

When administration of the medication requires ongoing professional health judgment, an individual health plan shall be developed by licensed health personnel working under the auspice of the school with collaboration from the parent or guardian, individual’s health care provider or education team pursuant to 281.14.2(256). Students who have demonstrated competence in administering their own medications may self-administer their own inhalers and epinephrine auto-injectors. A written statement by the student's parent/guardian shall be on file requesting co-administration of medication, when this competence has been demonstrated. By law, students with asthma, airway constricting diseases, respiratory distress, or students with a risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents/guardians and prescribing licensed health care professional regardless of competency.

Persons administering medication shall include authorized practitioners, such as, licensed registered nurses and physicians, and persons to whom authorized practitioners have delegated the administration of medication (who have successfully completed a medication administration course conducted by a registered nurse or pharmacist that is provided by the department of education). The medication administration course is completed every five years with an annual procedural skills check completed with a registered nurse or a pharmacist. A record of course completion shall be maintained by the school.

A written medication administration record shall be on file including:

• Date

• Student’s name

• Prescriber or person authorizing administration

• Medication

• Medication dosage

• Administration time

• Administration method

• Signature and title of the person administering medication

• Any unusual circumstances, actions, or omissions.

Medication shall be stored in a secured area unless an alternate provision is documented. The development of emergency protocols for medication-related reactions is required. Medication information shall be confidential information as provided by law.

Disposal of unused, discontinued/recalled, or expired abandoned medication shall be in compliance with federal and state law. Prior to disposal school personnel shall make a reasonable attempt to return medication by providing written notification that expired, discontinued, or unused medications needs to be picked up. If medication is not picked up by the date specified, disposal shall be in accordance with the disposal procedures for the specific category of medication.

Legal Reference: Disposing on Behalf of Ultimate Users, 79 Fed. Reg. 53520, 53546 (Sept.9, 2014).

Iowa Code §§124.101(1), 147.107, 152.1, 155A.4(2); 280.16; 280.23.

281 IAC14.1

655 IAC §6.2(152).

281 IAC § 14.1, .2

Cross Reference: 506 Student Records

507 Student Health and Well-Being

603.02 Special Education

607.02 Student Health Services

Approved: 11/01/2004

Reviewed: 05/12/2014

Revised: 01/18/2010, 05/16/2016, 04/15/2019, 08/15/2022, 10/16/2023, 09/16/2024

dawn.gibson.cm… Tue, 04/06/2021 - 10:55

507.02E1 - Authorization- Asthma Airway Constricting or Respiratory Distress Medication Self-Administration Consent Form

____________________________________ ___/___/___ ________________________ ___/___/___
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/guardians 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 or epinephrine auto-injector;
- 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 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, 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 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 use of 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, bronchodilator 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 Education 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.

I authorize the Independence school nurses to contact the prescriber to obtain necessary signature(s).

/ /
Parent/Guardian Signature (agreed to above statements) Date

Parent/Guardian Address Home Phone Business Phone Emergency Phone

Self-Administration Authorization Additional Information

dawn.gibson.cm… Tue, 04/06/2021 - 11:19

507.02E2 - ParentalGuardian Authorization and Release Form for the Administration of Prescription Medication to Students

Independence Community School District
Parental/Guardian Permission for Administering Medication at School

Student Name ______________________________________ DOB ___________________________

Medication _________________________________________________________________________

Reason for Medication ________________________________________________________________

Dose ______________________________Time to be given ___________________________________

Physician/Prescriber name __________________________________Phone Number ______________

Give on Early Out Days: Yes _______ No ________ Give on Late Start Days: Yes _______ No _______

I request that the medication be administered by a qualified staff person according to the written directions given. I agree that school personnel may contact the prescriber as needed and that medication information may be shared with school personnel who need to know. I understand the law provides that there shall be no liability for damages as a result of the administration of medication where the person administering the medication acts as an ordinary reasonably prudent person would under the same circumstances and that the school district and the school nurse are to incur no liability, except for gross negligence, as a result of injury arising from the administration of medication. I will comply with the procedure listed on the back of this form related to the administration of medication at school.

Parent/Guardian name ________________________________________________________________

Signature ___________________________________________________________________________

Date__________________________________Home Phone___________________________________

Cell phone _________________________________ Email ____________________________________

MEDICATION WILL NOT BE GIVEN IF IT HAS EXPIRED OR IT HAS AN IMPROPER LABEL. PLEASE CHECK THE CONTAINER BEFORE SENDING IT TO SCHOOL

PERMISSION FOR DISPOSAL OF UNUSED MEDICATION AT THE END OF THE SCHOOL YEAR – Please check one

_____I will pick up any unused medication at the end of the school year.

_____Please send any unused medication home with my child. The school district will not be responsible for the medication once it is in the possession of my child.

Parent/Guardian signature _____________________________________Date ____________________

Independence Community School District
Request to Administer Medication in Schools
Information and Procedures

All medications should be taken before or after school hours whenever possible. However, it is understood that certain drugs may be required during the school day. These students should have medication available and administered in a manner which is compliant with school district policy.
Medication shall be administered when the student’s parent/guardian provides a signed and dated written statement requesting medication administration and the medication is in the original, labeled container, either as dispensed by the pharmacy or in the manufacturer’s container.
Prescription medication: A current pharmacy labeled container can serve as the written prescriber’s order. A second labeled medication container can be obtained free of charge for school use by asking the pharmacist.
Over the counter/non-prescription medication will be given only with parent/guardian written authorization. Over-the-counter/non-prescription medications are to be provided by the parent/guardian and sent to school in the original medication container with the student’s name attached. This procedure will safeguard your child against over medicating and possible unforeseen reactions.
The parent/guardian is responsible for submitting a new prescriber’s order form to the school each time there is a change of dosage or time of administration. Prescriber’s orders may be faxed to the school.
To ensure the safety of all children, we request that a parent or another responsible adult deliver all medications to the health office when possible. If your child brings the medication to school, please place the labeled medication bottle in a sealed envelope with the number of tablets/capsules that are enclosed written on the outside of the envelope.
The first dosage of any new prescription should be given at home so the child can be more closely observed for possible side effects and/or adverse reactions.
The parent/guardian is responsible for notifying the school nurse when a medication has been discontinued or changed.
No medication will be continued beyond the school year in which it is ordered.
The Independence Community School District does not assume responsibility for medication not prescribed by a physician/prescriber or medication administered by a student himself/herself.

               Nurse/Appointed Personnel          Nurse/Appointed Personnel          Nurse/Appointed Personnel
               East Elementary West Elementary Jr Sr High School
               319-332-0533 319-332-0589 319-332-0720

dawn.gibson.cm… Tue, 04/06/2021 - 11:25

507.02E3 - Parental/Guardian Authorization and Release Form for Independent Self Carry and Administration of Prescribed Medication or Independent Delivery of Health Services by the Student

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

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 provided 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

lschaul@indeek12.org Thu, 10/19/2023 - 14:39

507.02E4 - Parental/Guardian Authorization and Release Form for the Administration of Voluntary School Stock of Over-the-Counter Medication to Students

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

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.
- 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/Guardian Signature Date

__________________________________________ _________________________

Parent/Guardian Address Home Phone

lschaul@indeek12.org Thu, 10/19/2023 - 14:43