Microsoft word - 1702 revised 5-2-11.docx

Wake County Public School System  
Form‐ 1702 Parent Request and Physician’s Order Form for Medication 
Student Name____________________________________DOB__________School_________________School Year_______
Route – How to
Medication Log
Name of Medication
Time(s) to Give
Diagnosis
(Right Medication)
(Right Amount)
(Right Time)
(Right Route)
MEDICATION
MEDICATION
EMERGENCY
Physician Printed Name: __________________________ Physician Signature: ______________________________Date:__________ Telephone: ______________
Wake County Public School System  
Form‐ 1702 Parent Request and Physician’s Order Form for Medication 
To be completed by Parent:
I understand that:
Non-medical personnel conduct the medication administration. It is my responsibility to have an adult transport the medication to school. If medication is not available at the school 911 will be called for emergencies. If my child participates in WCPSS before/after-school activities/sports, I will assume responsibility for contacting the advisor/coach of my child’s medical condition. I will provide extra emergency medications that may be needed during the activity. I may contact the school nurse if assistance is needed in instructing the advisor in a medical procedure or if a copy of the information needs to be shared with them. I request that:
My child be administered the medication as indicated in the physician’s order. If an emergency injection is ordered, I give permission for the School Nurse to instruct designated staff in the administration technique. I authorize:
The release and exchange of medical information between my child’s physician, school nurse and Wake County Public School System (WCPSS) that is necessary in carrying out services for my child. I hereby give my permission for my child to receive medication during school hours. This medication has been prescribed by a licensed physician.
I hereby release the Board of Education and their agents and employees from any and all liability that may result from my child taking the prescribed medication.
Parent/Guardian Signature:________________________________________Date:______________________
Student Self-Carry and Self Administration of Emergency Medication
To be completed by Physician:
To be completed by Parent:
The student must have the medication(s) listed on the reverse side during the school day or at I request and give permission for my child to carry and give the medication listed on the reverse school sponsored events in order to function at school. Adult supervision is not needed. The
side during the school day, at school-sponsored activities or while in transit to or from school. student has been instructed in the treatment plan, self-administration of the listed medication(s) Adult supervision is not needed.
and has demonstrated the skill level necessary to self-administer medications for: … I understand that:
I shall provide to the school back-up medication (in addition to what student will For Epinephrine Auto Injector Only:
My child will be required to demonstrate the skill level necessary to use the self- In the event the student is experiencing respiratory difficulty and is unable to administer the administered medications to school staff trained by the school nurse. Epinephrine Auto Injector the School Nurse will train designated school staff to administer the My child will be subject to disciplinary action if medication is used in any other ________________________________________________________ For Epinephrine Auto Injector Only:
In the event my child is experiencing respiratory difficulty and is unable to administer the Epinephrine Auto Injector ordered by the physician, a trained school staff member may administer ________________________________________________________ the Epinephrine Auto Injector and call 911. I have observed my child demonstrate the necessary skill level to implement the care plan prescribed by his/her health care provider Parent Signature: ______________________________________ Date: ______ __________ To be completed by student at school:
To be completed by school nurse:
… I have demonstrated the use of my medication to the school staff listed … I plan to keep my medication and equipment with me at school … I have observed the student indicated above verbalize and demonstrate the skill level … I will use only as prescribed by my doctor necessary to use the medication prescribed by the above physician … I will not allow any other person to used my medication … I will notify a school staff member if I am having more difficulty than usual with my Student Signature:_______________________________________ Date:______________ Nurse Signature:_________________________________ Date:________________ WCPSS 5/2011 

Source: http://stemec.wcpss.net/wp-content/uploads/2011/10/1702_parent_request_and_physicians_order.pdf