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.

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                                                                     Date

______________________________________________________________________________

Address                                                                                                           Phone

I authorize the school nurse to administer the above medication.  The school nurse will notify me if she is unable to give the medication.

______________________________________________________________________________

Parent Signature                                                                                               Date