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Atascadero USD |  E  5141.21  Students

Administering Medication And Monitoring Health Conditions   

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Physician's Recommendations For Medication

This form is to be filled in and signed by a licensed physician. The form should then be signed by the parents/guardians and returned to the school.


Student's Last Name First Middle Age Birth Date Month Day Year


Name of School Name of Principal Name of Teacher Type of Class Grade

The law allows any person to assist in carrying out a physician's recommendation. The school recognizes the desirability of following physician's recommendations as nearly as possible at school, just as does a parent at home or any other person (not necessarily a nurse) if the physician requests his/her assistance. The fact that this is a service or accommodation which the school is not legally required to perform is recognized by all parties signing this form, and in so signing they agree to hold the District, its officers, employees or agents, harmless from all liability, suits, claims of whatever nature or kind which might arise out of these arrangements.

Do you wish this child to receive medication at school? ( YES ( NO

If yes, please fill in the following blanks:

Form Observed or Assisted

(tablet, pill, Number to Approximate by Whom (self, teacher

Name of Medication capsule, etc.) be Taken Time of Day , nurse, etc.)



Precautions, if any

How is medicine to be brought to school:

By whom (student, parent, etc.)?

How often (daily, weekly, etc.)?

In what kind of container (envelope, bottle, plastic container)?

Does the physician wish to be able to talk briefly by telephone with someone (teacher, nurse, principal, psychologist) at intervals (weekly, monthly, quarterly) to see how this child is faring? If so, indicate:

Person(s) and intervals , and

you will be notified as to numbers and times at which the person(s) may usually be reached at school by telephone.

IMPORTANT: Please discontinue this request as of the following date.

Month Day Year

After this date, changes or continuance of these arrangements must be secured by filling out a newly dated copy of this form.

Signature Address Telephone No. Date


MD. No.

Physician Mo/Day/Yr

Parents' or Guardians' Full Name Mo/Day/Yr

Parent's or Guardian's Full Name Mo/Day/Yr

Background Information


The purpose of allowing medication to be given to students by authorized school personnel is to help provide for their general welfare by following the instructions of their physicians. This position is clarified by the intent seen in the following sections from the Nursing Practice Act (Chapter 6 commencing at Section 2700) Division 2 of the Business and Professions Code):


"The performance by any person of such duties as required in the physical care of a patient and/or carrying out medical orders prescribed by a licensed physician: provided, such person shall not in any way assume to practice as a professional, registered, graduate or trained nurse." (Business and Professions Code Section 2727 (e)).


"This chapter confers no authority to practice medicine or surgery." (Business and Professions Code 2726)


The procedures covering medication brought to school to be taken by students according to the provisions listed on the preceding form will be expedited if the following procedures are used:

1. Two copies of the form are supplied: one for the school files and one for the person authorized to administer the medication.

2. Only medication prescribed by the student's physician as being necessary to be taken by the student in the manner listed on this form should be brought to school.

3. Such medication should be taken by the student in accordance with instructions from the physician listed on this form.

4. Medication brought to school to be given to the student according to the provisions listed on this form should be in containers which are clearly marked with the name of the student; the name of the prescribing physician; an identification number or name of the medication; the druggist who dispensed the medication or the manufacturer; and the amount of medication to be taken at specified times or in specific situations.

5. All medications should be kept in a secure place. Any special instructions for storage or security measures of any medication should be written by the physician and given to school personnel so that such instructions can be followed.


version: October 5, 1999 Atascadero, California