Requirements to Self-Administer and Self Carry Medication

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    Requirements for Students to Self-Administer/Self Carry Medication During the School Day or at School Sponsored After School Events

    Dear Parent/Guardian:  ▁▁▁▁▁▁▁▁▁▁▁▁                                                  Date: ▁▁▁▁▁▁

    Student Name: ▁▁▁▁▁▁▁▁▁▁▁▁ Teacher: ▁▁▁▁▁▁▁▁▁▁▁▁               Grade: ▁▁▁▁▁▁

    If school nursing personnel receive a request from a parent/guardian and licensed prescriber to permit a student to carry and self-administer their own prescribed medications, such decisions will be made on an individual basis and in accordance with the following criteria:
    • The health care problems are severe enough to self-carry (particularly asthmatic or allergic conditions)
    • The licensed prescriber has provided an order directing that the student be allowed to carry their medication and self-administer
    • The parent/guardian has requested permission for the student to self-carry, self-administer
    • The parent/guardian assume responsibility regarding the monitoring of the student on an ongoing/daily basis to ensure that the student is carrying and taking the medication as ordered
    • The student demonstrates compliance in consistently and responsibly taking their own medication
    • The student assumes the responsibility for carrying properly labeled medication in original container on his/her person or keeping in school or physical education locker.
    • The school nurse has completed a nursing assessment which documents the student’s competence in self-carry, self-administration. Sample criteria attached – see page 2

    This privilege may be reassessed or revoked if the student cannot consistently and responsibly take their own medication.

    Thank you in advance for your cooperation,

    School Nurse: ▁▁▁▁▁▁ School:▁▁▁▁▁▁
    Phone #:▁▁▁▁▁▁ Fax:▁▁▁▁▁▁ Email:▁▁▁▁▁▁

    Determination of Self-Directed Students Criteria for Consistently and Responsibly Taking Medication

    The student:

    • Recognizes his/her medication
    • Knows how much medication he/she takes
    • Know what time his/her medication is needed during the school day
    • Knows why he/she takes this medication
    • Knows what happens when he/she does not take their medication
    • Knows when to refuse to take his/her medication when appropriate
    • Knows how to self-administer medication from original labeled pharmacy container or original OTC container (or is able to direct staff member to assist)