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315

Appendix III - Instructions for Administration of Medication Form 315-3

Procedures

Instructions for Administration of Medication

 

 

Note:         All medications must be in their original containers with original labels and instructions.

 

Name of Student:  ________________________________________________________________

 

Name of Parent:  _________________________________________________________________

Address:  ______________________________             Phone (Home):  _______________________

_____________________________________             (Work):  _____________________________

 

Name of Physician:  _________________________     Clinic:  ______________________________

Address:  _________________________________     Phone:  _____________________________

 

Name of Medication:  _____________________________________________________________

Purpose of Medication:  ___________________________________________________________

Prescribed Dosage:  ______________________________________________________________

Frequency of Dosage:  ____________________________________________________________

Starting Date (for administration of medication):  ________________________________________

Completion Date (for administration of medication):  ____________________________________

 

Possible side effects if medication is not administered according to the prescribed schedule:

______________________________________________________________________________

______________________________________________________________________________

Precautions to be taken in storing the medication:  ______________________________________

______________________________________________________________________________

Student’s ability to self-administer the medication:  _____________________________________

______________________________________________________________________________

 

Parent’s Signature:  ___________________________________           Date:  ___________________

 

Physician’s Signature:  ________________________________             Date:  ___________________

 

 

Physician’s Protocol for Treatment:  ______________________________________________________________________________

                                                                                                   ______________________________________________________________________________

                                                                          

Administrative Procedure 315 - Form 315-3

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October, 2009