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School Year:  _______________________________________________
Student’sName:___________________________________  Birth Date:_______________________________
School:_______________________________ Grade:________ Teacher:_______________________________ 
TO BE COMPLETED BY HEALTHCARE PROVIDER:
This order can only be signed by Physician (MD, DO), Dentist, Nurse Practitioner (NP, FNP, PNP, APRN/PP), or Certified Physician’s Assistant. Utah Law (53a-11-501) requires that medication administered during school hours must be medically necessary.  

*** ONLY ONE MEDICATION PER FORM ***

Diagnosis: ______________________________________________
Medication:  ____________________________________________   Duration To Be Given:  ________________________________
Dosage:  ______________________________     Time:  ______________________    Route:  _______________________________
Reportable Adverse Reactions/Side Effects: _______________________________________________________________________
___________________________________________________________________________________________________________
Special Instructions:  _________________________________________________________________________________________

MEDICATION SELF-ADMINISTRATION AUTHORIZATION
According to Utah State Law, students are only allowed to carry and self-administer epinephrine auto injectors, asthma inhalers and insulin. The above named student is under my care and has been trained in self-administration of the following medication, and is capable of carrying and self-administering the indicated medication:

[ ] Auto-Injectable Epinephrine                         [ ] Inhaler                         [ ] Insulin

Name of Healthcare Provider:  __________________________________________________ Phone:  _________________________
Healthcare Provider Signature:  _________________________________________________  Date:  __________________________

PARENTAL RESPONSIBILITIES:

  • Parent must furnish the school with a completed School Medication Authorization Form prior to any medications being administered by school personnel.
  • The medication must be delivered to the school by the parent in the original container, labeled with the child’s name, medication, time, dosage, and healthcare provider’s name.
  • All medication must be delivered to the school by an adult and picked up by an adult within two (2) weeks of last dose given.
  • If there is a change in the medication or medication dosage, a new School Medication Authorization Form must be completed before school personnel can administer the new medication or new medication dose.

I UNDERSTAND THAT BY SIGNING THIS FORM:

  • I am giving permission to the school personnel to contact the healthcare provider regarding this medication.
  • I am giving permission for this medication to be administered by someone other than a licensed nurse who has been appointed by the school administrator.
  • School personnel cannot give the following:
    • The 1st dose of a new medication OR the 1st dose of a dosage change of any medication.

Parent Signature:________________________________________________ Date:________________________ 

Emergency Phone Number(s): _________________________________________________________________
School Nurse Signature:  _________________________________________ Date:________________________

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