Sample Medication Administration Plan

Name of student__________________________________ Date of Birth__________ 

School__________________________________________________Grade_________  

Parent/guardian name________________________________________

Home telephone____________________________________      	Business telephone__________________________________

Emergency telephone________________________________		Cell Phone ________________________________________

Food/drug Allergies____________________________________________________________________________________________________  

Diagnoses:_______________________________________________________                                            													(if not a violation of confidentiality)  

Name of Medication:________________________________________________________  

 Name of licensed prescriber___________________________________________

Date Ordered___________________________  Duration of Order_____________

Dosage______________  Frequency_________________  Route of Administration____________________________  Expiration Date of Medications 

Received____________

Specific Directions, e.g., times to be given:_____________________________________________________________________________________

Possible Side Effects, Adverse Reactions:____________________________________________________________________________________________________________

Quantity of Medication Received by School and Date:__________________________________________________________________________________________________ 

Delegated to (if applicable):    _____________________________________________              				

Back-up Plans (if delegatee unavailable):____________________________________________________________________________________________________________

Plan for Field Trips:__________________________________________________________________________________________________________________

Plans for teaching self administration, if applicable:____________________________________________________________________________________________________

Other persons to be notified of medication administration (with parental permission):_________________________________________________________________________

Other medications being taken by the student (if not in violation of confidentiality):__________________________________________________________________________

Location where medication administration will occur: _____Health Room  _____Other (specify)_____________________________________________________________

Plan for monitoring medication, if needed:________________________________________________________________________________________________________

School Nurse Signature______________________________________________	Parent/Guardian Signature_________________________________

Date______________________                   								Date ____________________

Student’s Signature, if appropriate__________________________

  										Date ____________________

(Medication order and parent/guardian authorization may be attached to this form.)