Oliver Ames High School 100 Lothrop Street North Easton, MA 02356 Tel. (508) 230-3210 Fax (508) 238-7325

Wesley H. Paul Thomas J. Flanagan Principal Assistant Principal

Catherine Queally Assistant Principal

Dear Parent/Guardian,

We would like to inform you of the policies that have been put in place to ensure the health and safety of students needing medication during the school day. These policies are in compliance with state mandated regulations. The following forms must be completed and returned to the school nurse before any medication is given at school.

1. Signed consent by the parent or guardian for the nurse to give the medicine and/or for the student to self-administer their medication, (as in the case of emergency medications- Albuterol and EpiPen.) 2. Signed licensed prescriber order. The written medication order form should be taken to the student’s licensed prescriber, (your child’s physician, nurse practitioner or other authorized prescriber) for completion and returned to the school nurse. This order must be renewed as needed and at the beginning of each academic year prior to the nurse administering any medication or prior to plans for self administration.

Medications must be delivered to the school in a pharmacy or manufacturer labeled container by you or a responsible adult whom you designate. Please ask your pharmacy to provide separate labeled bottles for school and home. The supply of medicine delivered to the school should be no more than a thirty-day supply. Pills will be counted and recorded when they are delivered.

Medication must be given directly to the school nurse or, in the case of emergency medications, the school principal. A mutually convenient delivery plan should be prearranged by contacting the school nurse. Please call in advance for an appointment to drop of medications.

If your student would like to carry their inhaler or Epi pen on them, they are encouraged to do so. The same forms will need to be filled out and kept on file in the health office. The student will need to meet briefly with the nurse to ensure that he or she meets the criteria to be cleared to carry their own emergency medications. Parent(s) and the student are responsible to have the appropriate emergency medications with the student at all times, including extracurricular activities and field trips. For more information on the medication policy and forms please refer to www.oliverames.org.

Thank you for your cooperation,

Lynne LeBlanc, RN, BSN

Phone: 508-230-3210 ext 1405 or email: [email protected] Fax: 508-230-3213 MEDICATION ADMINISTRATION IN SCHOOL Part A PARENT/GUARDIAN AUTHO ATON FOR PRESCRIPTION/MEDICATION ADMINISTRATION ______

Student’s Name______Date of Birth______Parent/Guardian Name (please print)______Home Tel. #______Cell #______Work Tel. #______Emergency #______If parent/guardian unavailable, other person to be notified in case of medical emergency.______Phone #______

My son/daughter is currently receiving the following medications at home and school (to be completed if not a violation of confidentiality):______

My son/daughter has the following food or drug allergies:______

1. I give permission for the school nurse or school personnel designated by the school nurse to give the following medication______

Prescribed by ______, to______(Licensed prescriber) (Name of student)

2. I give permission for my son/daughter to self-administer medication if the school nurse determines it is safe and appropriate. Yes______No______

3. I give permission to the school nurse to share with his/her teachers information relevant to the prescribed medication as he/she determines appropriate for my son’s/daughter’s health and safety. Yes______No______

4. I hereby give my permission to the school nurse ______in my child’s building or her designate to consult with Dr. ______by telephone, in writing, or in person regarding my child’s medication and health status.

I understand I may retrieve the medication from the school at any time, however the medication will be destroyed if it is not picked up within one week following termination of the order or by the last day of the school year.

Parent/Guardian Signature ______Date______

Relationship to student______MEDICATION ADMINISTRATION IN SCHOOL Part B. MEDICATION ORDER

(To be completed by Physician, Nurse Practitioner, or other authorized by Chapter 94C) *Whenever possible, medication should be scheduled at times other than school hours. Medication will be stored at room temperature unless otherwise specified. ______

School:______School Year: 20__- 20__

Student:______D.O.B.___/___/___ Grade:______

Address:______

Allergies:______

Name of Licensed Prescriber:______Tel.#______

Diagnosis:______

Medication:______Dose:______Route______

Frequency:______Time(s) of Administration:______

Specific directions or information for administration:______

______

Date of order:______Discontinuation Date:______

Possible side effects, adverse reactions or contraindications to be observed:

______

Consent for self-administration (providing the school nurse determines it is safe and appropriate.) Yes______No ______

Authorized Prescriber Signature:______

Date:______