Students may be required to take medication during the school day and may need prescription and non-prescription medication to participate in their educational program. These students shall receive medication concomitant with their educational program.
Medication is administered by the parent, physician, school nurse, or in the nurse's absence, by a person who has successfully completed an administration of medication course. The course is conducted by a registered nurse or licensed pharmacist provided by the Department of Education. The medication adminstration course is completed every five years with an annual procedural skills check completed with a registered nurse or pharmacist. A record of course completion will be maintained by the school District.
Students who have demonstrated competence in administering their own medications may self- administer their medication as long as all other relevant portions of this policy have been complied with by the student and the student’s parent or guardian. A written statement by the student's parent/guardian shall be on file requesting co-administration of medication, when competence has been demonstrated. By law, students with asthma, other airway constricting diseases. respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon approval of their parents and prescribing physician regardless of competency.
Medication will not be administered without written authorization that is signed and dated from the parent or legal guardian and the medication must be in the original container which is labeled by the pharmacy or the manufacturer with the name of the child, name of the medication, the time of the day which it is to be given, the dosage, and the duration. Written authorization will also be secured when the parent requests student co-administration of medication when competency is demonstrated. When administration of the medication requires ongoing professional health judgment, an individual health plan will be developed by the licensed health personnel working under the auspice of the school with collaboration with the student, the parent or guardian, individual's health care provider or education team pursuant to 281.14.2(256). It is the parent’s responsibility to ensure that the medication is current; that all information regarding the medication is current; and that the information provided to the district, including, but not limited to the written authorization, is current.
A written record of the administration of medication procedure must be kept for each child receiving medication including the date; student's name; prescriber or person authorizing the administration; the medication and its dosage; the name, signature, and title of the person administering the medication; and the time and method of administration and any unusual circumstances, actions or omissions. Medication shall be stored in a secured area unless an alternate provision is documented. Emergency protocols for medication-related reactions is required. Medication information shall be kept confidential as provided by law.
The school nurse, or in the nurse's absence, the person who has successfully completed an administration of medication course reviewed by the Iowa Board of Pharmacy Examiners will have access to the medication which will be kept in a secured area. Students may carry medication (including but not limited to inhalers and epi-pens) only with the approval of the parents and building principal of the student's attendance center. Emergency protocol for medication-related reactions will be in place.
Disposal of unused, discontinued/recalled, or expired abandoned medication shall be in compliance with federal and state law. Prior to disposal, school personnel shall make a reasonable attempt to return medication by providing written notification that expired, discontinued or unused medications need to be picked up. If medication is not picked up by the date specified, disposal shall be in accordance with the disposal procedures for the specific category of medication.
The school nurse is responsible for developing rules and regulations governing the administration of medication, prescription and nonprescription, including emergency protocols, to students and for ensuring persons administering medication have taken the prescribed course and periodically review the prescribed course. Annually, each student is provided with the requirements for administration of medication at school.
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Approved: 8/14/89 Reviewed: 6/10/19 Revised: 12/14/09; 5/13/13, 7/14/ 25
______________________________________________________ _______________________ ____________________
Student Name (Last, First, Middle) Birthday Date
In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto- injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency.
The following must occur for a student to self-administer asthma medication, bronchodilator canisters or spacers, other airwayconstricting disease medication or to self-administer an epinephrine auto-injector:
• Parent/guardian provides signed, dated authorization for student medication self-administration.
•Parent/guardian provides a written statement from the student’s licensed health care professional (A person licensed under chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under chapter 152 or 152E and registered with the board of nursing, or a physician assistant licensed to practice under the supervision of a physician as authorized in chapters 147 and 148C) containing the following:
•The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.
• Authorization shall be renewed annually. In addition, if any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.
Provided the above requirements are fulfilled, the school shall permit the self-administration of the prescribed medication by a student while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before-school or after-school care on school-operated property. If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent. Pursuant to state law, the school district or and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine auto-injector by the student as provided by law.
ASTHMA,AIRWAY CONSTRICTING, OR RESPIRATORY DISTRESS MEDICATION SELF-ADMINISTRATION CONSENT FORM
______________________________________ ____________ __________ __________
Medication Dosage Route Time
____________________________________________________________________________________________________________ Purpose of Medication & Administration /Instructions
_________________________________________________________________________ _________________________________ Special Circumstances Discontinue/Re-Evaluate Follow-up Date
_____________________________________________________________________________ ________________________ Prescriber’s Signature Date
___________________________________________________________________________ __________________
Prescriber’s Address Emergency Phone
I request the above-named student possess and self-administer asthma medication, bronchodilators canisters or spacers, or other airway constricting disease medication(s) and/or an epinephrine auto-injector at school and in school activities according to the authorization and instructions.
I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or an epinephrine auto-injector or for supervising, monitoring, or interfering with a student's self- administration of medication or use of an epinephrine auto-injector.
I acknowledge that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or use of an epinephrine auto-injector by the student.
I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.
I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.
I agree the information is shared with school personnel in accordance with the Family Educational Rights.and Privacy Act (FERPA) and any other applicable laws
I agree to provide the school with back-up medication approved in this form.
Student maintains self-administration record.
______________________________________________________________ __________________ Parent/Guardian Signature (agreed to above statement) Date
_____________________________________________________________________________ _______________________ Parent/Guardian Address Home Phone
________________________________________________ Business Phone
Any Additional Self-Administration Authorization Additional Information:
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Approved: 3/10/03 Reviewed: 6/10/19 Revised: 12/14/09; 5/13/13; 7/14/25
__________________________________________ ___/___/___ ___/___/___
Student's Name (Last, First, Middle) Birthday Date
School medications and special health services are administered following these guidelines:
Parent has provided a signed, dated authorization to administer prescription medication and/or provide special health services listed
Electronic signatures meet the requirement of written signatures.
The prescribed medication is in the original, labeled container as dispensed.
The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer, and date.
Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.
_______________________________________________ __________ _________ ___________
Prescribed Medication Dosage Route Time at School
Special Health Services and instructions, as indicated: __________________________________________________
_____________________________________________________________________________________________
Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services Listed: __________________
________________________________________________________________ __________________ Prescriber’s Signature & credentials Date
________________________________________________________________ __________________ Parent/Guardian Signature Date
________________________________________________________________ ___________________ Parent/Guardian address Home Phone
__________________
Business Phone
Additional Information: __________________________________________________________________________________________________
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Approved: 5/13/13 Reviewed: 6/10/19 Revised: 7/14/25
____________________________________ ___/___/___ ___/___/___
Student's Name (Last), (First), (Middle) Birthday Date
I request the above-named student (Parent/Guardian initial all that apply):
______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency. The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.
_____________________________ _____________ __________________
Prescribed Medication Dosage Time at School
______ Co-administer, participate in planning, management and implementation of special
health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school.The information provided by the parent for health service delivery is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year.
Special Health Services Delivery: _________________________________________________________ ____________________________________________________________________________________
Procedures for abandoned medication disposal shall be in accordance with applicable laws.
___________________________________________________ _________________
Prescriber’s Signature & credentials Date
___________________________________________________ _________________
Parent/Guardian Signature Date
___________________________________________________ _________________
Parent/Guardian address Home phone
Approved: 7/14/25 Reviewed: Revised:
_______________________________ _________ _________
Student's Name (Last), (First), (Middle) Birthday Date
The district supplies the following nonprescription, over-the-counter medications that are listed below. Generic brands may be substituted:
Acetaminophen administered per manufacturer label
Ibuprofen administered per manufacturer label
Benadryl (dyphenhydromine) administered per manufacturer label
Antacid administered per manufacturer label
Hydrocortisone cream administered per manufacturer label
Antibiotic ointment administered per manufacturer label
Aquaphor administered per manufacturer label
Throat Lozenges administered per manufacturer label
Cough Drops administered per manufacturer label
Voluntary school stock of nonprescription, over-the-counter medications are administered following these guidelines:
Parent has provided a signed, dated annual authorization to administer the nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature
The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.
All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the counter medication.
Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOT applicable.
Nonprescription, over-the-counter medications approved by the Federal Drug Administration that require emergency medical service (EMS) notification after administration are NOT applicable.
Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the Department of Education and annual medication administration procedural skills check.
Districts stocking the administration of a voluntary stock of nonprescription, over-the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:
when to contact the parent when a nonprescription medication, over the counter medication is administered;
documentation of the administration of the nonprescription, over-the-counter medication and parent contact;
a limit to the administration of a school’s stock nonprescription, over-the-counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school year;
the development of an individual health plan for ongoing medication administration or health service delivery at school.
I request that the above-named student receive the voluntary stock nonprescription, over-the-counter medications supplied by the school in accordance with the district guidelines and protocol.
__________________________________________ _____________
Parent Signature Date
__________________________________________ _____________
Parent/Guardian Address Home Phone
Approved: 7/14/25 Reviewed: Revised: