Lee’s Summit R-7 School District Medication Record 2015-2016 Student:______________________________________________DOB:___________________ Teacher/Gr/Rm:_____________________________ Year:______________ School:____________________ Date:____________ Medication:______________________________________ Label Instructions/Time:_______________________________________________________________________________ RN approval/date:_________________________________________________________________ Verbal Order approval/date:_____________________________________________________________ Dose change Date:______________ Medication:______________________________________ Label Instructions/Time:_________________________________________________________________ RN approval/date:_________________________________________________________________ Verbal Order approval/date:_____________________________________________________________ Special Instructions: _____refrigerate _____spacer _____other:_______________________________________________________________________________________________________________ 1

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August

X

September October

X

November December January

X X X

February March

X

April May

X

June July CODES: (A)Absent (D)Early Dismissal (DC)Discontinue (DW)Dose Withheld (F)Field Trip (0)No Show (N)None Available (S)Snow Day Weekend/Holiday/No School Signature of Person Administering Medication

Initials

Date

Date:_______________ Medication returned / destroyed

Date

Pharmacy

Rx #

Qty Received

Signature(s)

Amount:__________________________ Signature:___________________________________________________ Signature:___________________________________________________

Rev 2014

LEE’S SUMMIT R-7 SCHOOL DISTRICT MEDICATION CONSENT FORM

Name:_______________________________________ Date of Birth:_____________________ Age:__________ School: ____________________Grade /Teacher: ______________________

Known Drug Allergies (list) ________________________________________________________________________

*Medication must be in the original container and brought to the Health Room and picked

up by a parent/guardian* Name of Medication to be given at school: _______________________________________________________ Reason for Medication: ______________________________________________________________________ Dosage: _______________________________________________________ Time(s): ___________________ Dosage: _______________________________________________________ Time(s): ___________________ Physician’s Name:_________________________________________ Phone Number:_________________________ Physician’s Signature:___________________________________ Date:_______________________________ (Prescription label will suffice as physician signature) Do you want the mid-day dose given on early release day?

 Yes  No



I hereby give permission for my student to receive the above medication at school.



I have given the first dose of medication at home.



I hereby give permission for the school nurse to communicate with the prescribing physician.



I understand that all unused, discontinued and/or expired medication not picked up by a parent/legal guardian at the end of the school year will be destroyed.

Parent/Guardian Signature: _________________________________________ Date: _________________________

NOTICE Schools in this district are equipped with pre-filled epinephrine auto-syringes that can be administered in the event of severe allergic reactions that cause anaphylaxis. Epinephrine will be administered in accordance with written protocols provided by the authorized prescriber, except for students authorized to carry and self-administer epinephrine in accordance with LSR7 Board Policy.

There are some medications that the district does not delegate administration of to unlicensed personnel. For more information, see Board Policy JHCD: Administration of Medication to Students and Administrative Procedure JHCD -AP: Administration of Medication to Students at www.lsr7.org Rev 2014

Medication Record with parent permission form on back.pdf ...

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