ASTHMA MEDICATION SELF-ADMINISTRATION FORM

Student Name: _________________________________________________ Teacher: _____________ Grade________

The Missouri Safe Schools Act of 1996 provides for students to carry and self-administer lifesaving medications when the following criteria are met:

1) Written authorization by the parent/guardian

2) Medical history of students asthma on file at the school

3) Written asthma action plan/individual healthcare plan on file at school

4) Written authorization from the prescribing health care provider that child has asthma, has been trained

in the use of the medication and is capable of self-administration of the medication.

MEDICATION NAME ___________________________________ Dose ______________

Time or Interval _____________

Route/Inhalation device ____________________________________________________________________

Instructions ______________________________________________________________________________

________________________________________________________________________________________

MEDICATION NAME ___________________________________ Dose ______________ Time or Interval _____________

Route/Inhalation device _________________________________________Instructions ______________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

ALLERGIES: list known allergies to medications, foods, or air-borne substances _______________________

____________________________________________________________________________________________________

I, the parent or legal guardian of the student listed above, give permission for this child to carry and self-administer the

above listed medications. I have instructed my child to notify the school staff if one dose fails to relieve asthma symptoms

for 3 or more hours. I understand that, absent any negligence, the school shall incur no liablity as a result of any injury arising

from the self-administration of medication by my child.

Signature of parent or legal guardian ________________________________________________ Date __________

Parent/Guardian:

Name: ________________________________________________________________

 Home phone: ______________________ Work phone:

Address: _______________________________________________________________ ______________________

Name: ________________________________________________________________ Home phone: ____________

Address: _______________________________________________________________Work phone: ______________________

Emergency Contact:

Name: ________________________________________________________________________ Phone: ______________________

I, a licensed health care provider, certify that this child has a medical history of asthma, has been trained in the use of the

listed medication, and is judged to be capable of carrying and self-administering the listed medication(s). The child should

notify school staff if one dose of the medication fails to relieve asthma symptoms for at least 3 hours. This child understands

the hazards of sharing medications with others and has agreed to refrain from this practice.

Signature of Health Care Provider ____________________________________________________ Date __________________

Healthcare Provider:

Name: _____________________________________________________________________________________________

Fax: _____________________________________________________ Phone: _____________________________

Address: _________________________________________________City: ___________________________Zip: __________