AUTHORIZATION ASTHMA OR AIRWAY CONSTRICTING MEDICATION 

SELF-ADMINISTRATION CONSENT FORM

 

_____________________________    ___/___/___    _________________    ___/___/___

Student's Name (Last), (First)  (Middle)        Birthday         School              Date

 

In order for a student to self-administer medication for asthma or any airway constricting disease:

 

• Parent/guardian provides signed, dated authorization for student medication self-administration.

• Physician (person licensed under chapter 148, 150, or 150A, physician, physician's assistant, advanced registered nurse practitioner, or other person licensed or registered to distribute or dispense a prescription drug or device in the course of professional practice in Iowa in accordance with section 147.107, or a person licensed by another state in a health field in which, under Iowa law, licensees in this state may legally prescribe drugs) provides written authorization containing:

  • purpose of the medication, 

  • prescribed dosage, 

  • times or;

  • special circumstances under which the medication is to be administered.

• 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 is renewed annually.  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, a student with asthma or other airway constricting disease may possess and use the student's medication 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 If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed.

 

Pursuant to state law, the school district or accredited nonpublic school and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district or nonpublic school is to incur no liability, except for gross negligence, as a result of self-administration of medication by the student as established by Iowa Code § 280.16.

 

                                               

Medication        Dosage        Route                    Time

 

                                               

Purpose of Medication & Administration /Instructions

Code No. 507.2E1

Page 2 of 2

 

AUTHORIZATION-ASTHMA OR AIRWAY CONSTRICTING MEDICATION 

SELF-ADMINISTRATION CONSENT FORM

 

                                    /    /   

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 or other airway constricting disease medication(s) 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 for supervising, monitoring, or interfering with a student's self-administration of medication

• 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 Education Rights and Privacy Act (FERPA). 

• I agree to provide the school with back-up medication approved in this form.

 

                                    /    /   

Parent/Guardian Signature                     Date

(agreed to above statement)           

 

                                               

Parent/Guardian Address                    Home Phone

 

                                               

                                Business Phone

 

                                               

 

                                               

 

                                               

Self-Administration Authorization Additional Information       

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION 

OF PRESCRIPTION MEDICATION TO STUDENTS

 

_________________________________    ___/___/___    _________________    ___/___/___

Student's Name (Last), (First),  (Middle)              Birthday         School              Date

 

School medications and health services are administered following these guidelines:

 

• Parent has provided a signed, dated authorization to administer medication and/or provide the health service.

• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container. 

• The medication label contains the student’s name, name of the medication, directions for use, and date.

• Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.

 

                                                     

Medication/Health Care    Dosage            Route            Time at School

 

                                               

 

                                               

Administration instructions

 

                                               

 

                                               

Special Directives, Signs to Observe and Side Effects

 

    /    /   

Discontinue/Re-Evaluate/Follow-up Date

 

                                /    /   

Prescriber’s Signature                    Date

 

                                           

Prescriber's Address                    Emergency Phone

 

I request the above named student carry medication at school and school activities, according to the prescription, instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided to the Family Education Rights and Privacy Act (FERPA).  I agree to coordinate and work with school personnel and prescriber when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.

Code No. 507.2E2

Page 2 of 2

 

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION 

OF PRESCRIPTION MEDICATION TO STUDENTS

 

                                    /    /   

Parent's Signature                        Date

 

                                           

Parent's Address                        Home Phone

 

                                           

Additional Information                        Business Phone

                                               

       

                                               

 

                                               

Authorization Form

EXHIBIT 507.2E4

(CHART ATTACHED)

 

 

While the school district is not responsible for reporting, the following infectious diseases are required to be reported to the state and local public health offices:

Acquired Immune Deficiency Syndrome (AIDS)                                                   

Amebiasis                                                

Anthrax                                                    

Botulism                                                   

Brucellosis                                               

Campylobacteriosis                                 

Chlamydia trachomatis                            

Cholera                                                     

Diphtheria                                                

E. Coli 0157:h7                                       

Encephalitis                                             

Giardiasis                                                 

Hepatitis, viral (A,B, Non A-Non-B, Unspecified)                             

Histoplasmosis                                         

Human Immunodeficiency Virus (HIV) infection other than AIDS                                     

Influenza                                                  

Legionellosis                                            

Leprosy            

Leptospirosis    

Lyme disease   

Malaria

Meningitis (bacterial or viral)

Mumps

Parvovirus B 19 infection (fifth disease and other complications)

Pertussis (whooping cough)

Plague 

Poliomyelitis    

Psittacosis         

Rabies 

Reye's Syndrome

Rheumatic fever

Rocky Mountain spotted fever

Rubella (congenital syndrome)

Rubella (German measles)

Rubeola (measles)

Salmonellosis

Shigellosis

Tetanus

Toxic Shock Syndrome

Trichinosis

Tuberculosis

Tularemia

Typhoid fever

Typhus fever

Venereal disease

  Chancroid

  Gonorrhea

  Granuloma Inguinale

  Lymphogranuloma Venereum

  Syphilis

Yellow fever

 

Any other disease which is unusual in incidence, occurs in unusual numbers of circumstances, or appears to be of public health concern, e.g., epidemic diarrhea, food or waterborne outbreaks, acute respiratory illness.

(FORM ATTACHED)

 

 

Epidemiologic studies show that AIDS is a viral infection transmitted via intimate sexual contact or blood to blood contact.  To date, there is no recorded transmission to AIDS to family members who are non-sexual contacts. There has also been to transmission observed with medical personnel who directly care for and are exposed to AIDS cases.  Since there is no evidence of casual transmission by sitting near, living in the same household, or playing together with an individual with AIDS, the following guidelines are recommended for implementation in school systems throughout Iowa.

1. Routine screening of students for AIDS associated virus (HTLV-III/LAV) is not recommended.  Screening should not be a requirement for school entry.

2. Children diagnosed as having AIDS, or with laboratory evidence of infection with the IDS associated virus (HTLV-III/LAV), and receiving medical attention are able to attend classes in an unrestricted educational setting.  Siblings of infected children are able to attend school without restriction.

3. An appropriate alternative educational plan which may include a more restricted environment should be provided for the child diagnosed as having AIDS or laboratory evidence of infection with the HTLV-III/LV virus if:

   1. Cutaneous (skin) eruptions or weeping lesions that cannot be covered are present.

   2. Inappropriate behavior that increases the likelihood of transmission (i.e. biting or incontinence) is exhibited.

   3. The child is too ill to attend school.

4. Decisions as to educational management should be shared utilizing expertise of the physician, parent or guardian, public health personnel and those associated with the educational setting.

   1. Notification of the school should be through the school nurse or person responsible for school health who will notify only those necessary to assure optimal management.

   2. Notification should be by a process that would maximally provide patient confidentiality.  Ideally, this process should be direct person to person contact.

   3. If school authorities believe that a child diagnoses as having AIDS or with laboratory evidence of infection with the AIDS associated virus (HTLV-III/LV) has evidence of conditions described in #3, then the school authorities can dismiss the child from the class and request authorization from the child’s personal physician so that class attendance is within compliance with the school policy.

   4. If a conflict arises as to the child’s management, the case should be referred to the State Department of Health for review to determine the permissibility of attendance.

5. Since the child diagnosed as having AIDS or with laboratory evidence of infection with the AIDS associated virus (HTLV-III/LV) has a somewhat greater risk of encountering infections in the school setting, the child should be excluded from school if there is an outbreak of a threatening communicable disease such as chickenpox or measles until he/she is properly treated and/or the outbreak is no longer a threat to the child.

6. Blood or any other body fluids including vomitus and fecal or urinary incontinence in any child should be treated appropriately.  It is recommended that gloves be worn when cleaning up any body fluids.

   1. Spills should be cleaned up, the affected area washed with soap and water and disinfected with bleach (one part bleach to ten parts water), or another disinfectant.
   2. All disposable materials, including gloves and diapers, should be discarded into a plastic bag before discarding in a conventional trash system.  The mop should also be disinfected with bleach solution described in 6A.
   3. Toys and other personal non-disposable items should be cleaned with soap and water followed by disinfected with the bleach solution before passing to another person.  A normal laundry cycle is adequate for other non-disposable items.
   4. Persons involved in the clean-up should wash their hand afterward.

7. In-service education of appropriate school personnel should ensure that proper medical and current information about AIDS is available.

Approved     7/21/86            Reviewed    7-19-17             Revised   1/17/94  __

The herpes simplex virus and cytomegalovirus are ubiquitous agents infecting most of the population.  It is not possible with present medical knowledge and skills to totally prevent their transmission. Under ordinary circumstances it is not reasonable to exclude infected individuals from school unless those infected are too ill to attend.  Infection control is best accomplished by maintaining appropriate hygienic practices such as avoiding other people’s secretions and careful washing of contaminated hands. Under special circumstances when secretions cannot be adequately controlled because of individual behavior, it might be advisable to provide an alternative educational plan until the problem is resolved.

Approved     9/15/97               Reviewed    7-19-17             Reviewed    7/18/12     

Emmetsburg Community School District

Responsibilities of the Nurse from a Private Agency

For the well being of an ECS student that needs individual medical care

 

___(name of agency)_______ is responsible for the professional credentials that are required for a nurse to provide services in the Emmetsburg School District.  The agency is also required to schedule staff according to the activities roles of the nurse during the school day.  In the event that the agency does not have adequate nurse staffing and are not available to attend school or activities with the designated student, that student will need to be absent also.  The Parent/Guardian will need to be responsible or arrange or arrange for other sources for care.

 

The nurses schedule will be based on the scheduled classes and activities that the Emmetsburg School District develops for _________(Student)_______________.  Students medical care supplies will be provided through an arrangement between___(insurer)____,  parent, and /or _____(nursing agency)_________.

 

The Health Plan will help identify the necessary equipment the ECS will provide.  Any additional equipment or supplies needed for the student the agency, parent, or insurer will need to provide.

 

The agency nurse will be responsible for monitoring students vital signs and providing direct care as needed.  Along with medical care this agency nurse's role will be in charge of feedings for all meals & snacks, bathroom toileting & hygiene, changing clothing, & administering medications as prescribed.  Transportation arrangements & safety practiced during any change of positions.  Any specific needs will individually be considered to accompany certain situations.

 

*Please consider changes according to agency's expectations.

 

Mrs. Hinners

David Cole

 

 

Some students who require special education need special health services in order to participate in the educational program.  These students shall receive special health services in accordance with their individualized educational program.

 

A.    Definitions

"Assignment and delegation" - occurs when licensed health personnel, in collaboration with the education team, determine the special health services to be provided and the qualifications of individuals performing the health services.  Primary consideration is given to the recommendation of the licensed health personnel. Each designation considers the student's special health service. The rationale for the designation is documented. If the designation decision of the team differs from the licensed health professional, team members may file a dissenting opinion.

 

"Co-administration" - the eligible student's participation in the planning, management and implementation of the student's special health service and demonstration of proficiency to licensed health personnel.

 

"Educational program" - includes all school curricular programs and activities both on and off school grounds.

 

"Education team" - may include the eligible student, the student's parent, administrator, teacher, licensed health personnel, and others involved in the student's educational program.

 

"Health assessment" - health data collection, observation, analysis, and interpretation relating to the eligible student's educational program.

 

"Health instruction" - education by licensed health personnel to prepare qualified designated personnel to deliver and perform special health services contained in the eligible student's health plan.  Documentation of education and periodic updates shall be on file at school.

 

"Individual health plan" - the confidential, written, preplanned and ongoing special health service in the educational program.  It includes assessment, planning, implementation, documentation, evaluation and a plan for emergencies. The plan is updated as needed and at least annually.  Licensed health personnel develop this written plan with the education team.

 

"Licensed health personnel" - includes licensed registered nurse, licensed physician, and other licensed health personnel legally authorized to provide special health services and medications.

 

"Prescriber" - licensed health personnel legally authorized to prescribe special health services and medications.

 

"Qualified designated personnel" - persons instructed, supervised and competent in implementing the eligible student's health plan.

 

"Special health services" - includes, but is not limited to, services for eligible students whose health status (stable or unstable) requires:

            Interpretation or intervention,

            Administration of health procedures and health care, or

            Use of a health device to compensate for the reduction or loss of a body function.

 

"Supervision" - the assessment, delegation, evaluation and documentation of special health services by licensed health personnel.  Levels of supervision include situations in which licensed health personnel are:

            physically present.

            available at the same site.

            available on call.

 

B.    Licensed health personnel shall provide special health services under the auspices of the school.  Duties of the licensed personnel include the duty to:

        Participate as a member of the education team.

        Provide the health assessment.

        Plan, implement and evaluate the written individual health plan.

        Plan, implement and evaluate special emergency health services.

        Serve as liaison and encourage participation and communication with health service agencies and individuals providing health care.

        Provide health consultation, counseling and instruction with the eligible student, the student's parent and the staff in cooperation and conjunction with the prescriber.

        Maintain a record of special health services.  The documentation includes the eligible student's name, special health service, prescriber or person authorizing, date and time, signature and title of the person providing the special health service and any unusual circumstances in the provision of such services.

        Report unusual circumstances to the parent, school administration, and prescriber.

        Assign and delegate to, instruct, provide technical assistance and supervise qualified designated personnel.

        Update knowledge and skills to meet special health service needs.

 

C.    Prior to the provision of special health services the following shall be on file:

        Written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated.

        Written statement by the student's parent requesting the provision of the special health service.

        Written report of the preplanning staffing or meeting of the education team.

        Written individual health plan available in the health record and integrated into the IEP or IFSP.

 

D.    Licensed health personnel, in collaboration with the education team, shall determine the special health services to be provided and the qualifications of individuals performing the special health services.  The documented rationale shall include the following:

        Analysis and interpretation of the special health service needs, health status stability, complexity of the service, predictability of the service outcome and risk of improperly performed service.

        Determination that the special health service, task, procedure or function is part of the person's job description.

        Determination of the assignment and delegation based on the student's needs.

        Review of the designated person's competency.

        Determination of initial and ongoing level of supervision required to ensure quality services.

 

E.    Licensed health personnel shall supervise the special health services, define the level of supervision and document the supervision.

 

F.    Licensed health personnel shall instruct qualified designated personnel to deliver and perform special health services contained in the eligible individual health plan.  Documentation of instruction and periodic updates shall be on file at school.

 

G.    Parents shall provide the usual equipment, supplies and necessary maintenance for such.  The equipment shall be stored in a secure area. The personnel responsible for the equipment shall be designated in the individual health plan.  The individual health plan shall designate the role of the school, parents, and others in the provision, supply, storage and maintenance of necessary equipment.

Approved          2/19/01     _                Reviewed     3-25-2020                           Revised    7/18/12 __        

To implement the Wellness Policy, the following district specific goals have been established:

Goal 1 - Nutrition Education & Promotion: Schools will provide nutrition education and engage in nutrition promotion that help students develop lifelong healthy eating behaviors. The goals(s) for addressing nutrition education and nutrition promotion include the following:

• Provide students with the knowledge and skills necessary to promote and protect their health;

• Emphasize caloric balance between food intake and energy expenditure (promotes physical activity/exercise.

• Promote fruits, vegetables, whole grain products, low-fat and fat-free dairy products and healthy foods

Goal 2 - Physical Activity: Schools will provide students and staff with age and grade appropriate opportunities to engage in physical activity that meet federal and state guidelines, including the Iowa Healthy Kids Act. The goals(s) for addressing physical activity include the following:

• Promote the benefits of a physically active lifestyle and help students develop skills to engage in lifelong healthy habits;

• Engage students in moderate to vigorous activity during at least 50 percent of physical education class time;

• Encourage classroom teachers to provide short physical activity breaks (3-5 minutes), as appropriate;

• Ensure physical activity is not used for or withheld as punishment;

• Afford elementary students with recess according to the following:

  • At least 20 minutes a day;

  • Outdoors as weather and time permits

  • Encourages moderate to vigorous physical activity; and

• Scheduled to avoid extended periods of inactivity (ie periods of 2 hours or more)

 Goal 3 - Other School-Based Activities that Promote Student Wellness: Schools will support student, staff and parents’ efforts to maintain a healthy lifestyle, as appropriate. The goals(s) for addressing other school-based activities that promote student wellness include the following:

• Develop a plan to promote staff health & wellness

• Permit students to bring and carry water bottles filled with water throughout the day

Public Involvement: There is a process for permitting parents, students, representatives of the school food authority, teachers of physical education, school health professionals, the school board, administrators and the public to participate in the development, implementation and periodic review and update of the policy:

• The superintendent or superintendent’s designee invites suggestions or comments concerning the development, implementation and improvement of the school wellness policy. As such, interested persons are encouraged to contact the superintendent or superintendent’s designee.

NOTE:  School districts are required by federal law to have at least one specific wellness goal in each of the goal areas identified above. These goals areas include the following: nutrition promotion and education, physical activity and other school-based activities that promote student wellness. Options have been provided, but districts must remember the sample policy and sample regulation cannot be adopted in the current format. School boards and administration must make a choice for all text in italicized brackets.

 

NOTE: The Iowa Department of Education has tools and resources available to help with progress reports and other aspects of policy implementation and review. Please visit the School Wellness Policy webpage.

 

Approved: 07/15/15 Reviewed:  10/20/2021          Revised:  04/19/2023