Caldwell-West Caldwell Public Schools Authorization for Administration of Medication



Download 25 Kb.
Sana27.06.2017
Hajmi25 Kb.
Caldwell-West Caldwell Public Schools
Authorization for Administration of Medication

New Jersey law requires a physician’s written order and parent/guardian authorization for administration of any medication (prescription or over the counter). Only the school nurse or parent may administer the medication.


The medication must be in the original prescription container and properly labeled.
The parent/guardian must notify the nurse in writing or over the phone, of the amount of medication provided. The medication will not be dispensed without this verification, whether the initial dose or for subsequent refills.

To be completed by Physician:
Name of Student: _____________________________________________________________
Diagnosis/Illness: _____________________________________________________________
Medication: __________________________________________________________________
Dose: ___________________ Frequency: ___________________ Duration: ____________
Special Directions: ____________________________________________________________
Possible Side Effects: __________________________________________________________
I certify that the above information regarding this student is correct, and that administration of the medication to this student is necessary.

__________________________________________________ ________________________



Signature of Prescribing Physician/Physician Stamp Date
__________________________________________________ ______________________

Physician Address Physician Phone




Parent/Guardian Authorization:
I authorize the school nurse to administer the above medication.
______________________________________________________________________________

Parent/Guardian Signature Date


______________________________________________________________________________

Daytime Phone



1/11

Download 25 Kb.

Do'stlaringiz bilan baham:




Ma'lumotlar bazasi mualliflik huquqi bilan himoyalangan ©hozir.org 2020
ma'muriyatiga murojaat qiling

    Bosh sahifa
davlat universiteti
ta’lim vazirligi
O’zbekiston respublikasi
maxsus ta’lim
zbekiston respublikasi
davlat pedagogika
o’rta maxsus
axborot texnologiyalari
nomidagi toshkent
pedagogika instituti
texnologiyalari universiteti
navoiy nomidagi
samarqand davlat
guruh talabasi
ta’limi vazirligi
nomidagi samarqand
toshkent davlat
toshkent axborot
haqida tushuncha
Darsning maqsadi
xorazmiy nomidagi
Toshkent davlat
vazirligi toshkent
tashkil etish
Alisher navoiy
Ўзбекистон республикаси
rivojlantirish vazirligi
matematika fakulteti
pedagogika universiteti
таълим вазирлиги
sinflar uchun
Nizomiy nomidagi
tibbiyot akademiyasi
maxsus ta'lim
ta'lim vazirligi
махсус таълим
bilan ishlash
o’rta ta’lim
fanlar fakulteti
Referat mavzu
Navoiy davlat
haqida umumiy
umumiy o’rta
Buxoro davlat
fanining predmeti
fizika matematika
malakasini oshirish
universiteti fizika
kommunikatsiyalarini rivojlantirish
jizzax davlat
davlat sharqshunoslik