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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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Medication Administration in Private Approved Special Education School Residential Programs

Open PDF file, 289.87 KB,  ASERP Medication Administration Advisory (English, PDF 289.87 KB)
Open DOCX file, 299.47 KB,  ASERP Medication Administration Advisory (English, DOCX 299.47 KB)

Policies and procedures

Open PDF file, 49.81 KB,  Sample Policies and Procedures for the Administration of Medications (based no 105 CMR 210.000) (English, PDF 49.81 KB)
Open RTF file, 138.33 KB,  Sample Policies and Procedures for the Administration of Medications (based no 105 CMR 210.000) (English, RTF 138.33 KB)

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)

The Administration of Naloxone in Schools

Open PDF file, 129.83 KB,  The Administration of Naloxone in Schools (English, PDF 129.83 KB)
Open DOCX file, 39.16 KB,  The Administration of Naloxone in Schools (English, DOCX 39.16 KB)

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