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School Health Services: Sample policies and forms

The sample forms below are only a few of those available. Please see the Massachusetts Comprehensive School Health Manual for additional sample forms.

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Parent/guardian letter and authorization

Open PDF file, 7.85 KB,  Sample Parent/Guardian Letter (English, PDF 7.85 KB)
Open RTF file, 9.78 KB,  Sample Parent/Guardian Letter (English, RTF 9.78 KB)
Open PDF file, 7.99 KB,  Sample Parent/Guardian Authorization for Prescription Medication Administration (English, PDF 7.99 KB)
Open RTF file, 9.99 KB,  Sample Parent/Guardian Authorization for Prescription Medication Administration (English, RTF 9.99 KB)

Medication order form

Open PDF file, 8.63 KB,  Sample Medication Order Form (English, PDF 8.63 KB)
Open RTF file, 10.41 KB,  Sample Medication Order Form (English, RTF 10.41 KB)

Medication administration plan and daily log

Open PDF file, 8.98 KB,  Sample Medication Administration Plan (English, PDF 8.98 KB)
Open RTF file, 10.01 KB,  Sample Medication Administration Plan (English, RTF 10.01 KB)
Open PDF file, 21.07 KB,  Sample Medication Administration Daily Log (English, PDF 21.07 KB)
Open RTF file, 310.59 KB,  Sample Medication Administration Daily Log (English, RTF 310.59 KB)

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