Forms: Meds Epipen Cough Drop etc

Student Health Services:   Health Forms


Students requiring emergency care plan(s) and/or medication(s) that need to be given during school hours will need one or more of the following forms completed.

Prior to the beginning of each school year, emergency care plans and medication authorizations should be turned in to your child's school health office and reviewed with your Licensed School Nurse.

Click on the name of the form you wish to complete. Descriptions follow each form name.  Completed forms can be dropped off at any health office, emailed to Kpokrandt@pineisland.k12.mn.us or Faxed to 507.356.4130
  


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AUTHORIZATION FOR ADMINISTRATION OF MEDICATION:
Complete this form if your child needs a medication given during school hours.  A Health Care Provider’s signature is required for all prescription medications and for over-the-counter medications exceeding package recommendations. 

Would you like your child to have an opportunity to self carry (Grades 5-12):
Please complete the authorization for administration of medication form and note the following that is required.

Over the counter medications will require the following signatures: Parent (section 4), Nurse, Student (to be signed with consultation from the licensed school nurse).

Prescription medications require the following signatures: Physician, Parent (section 4), Nurse, Student (to be signed with consultation from the licensed school nurse).

*Please note that medication must be brought to school by an adult in the original labeled prescription container or in unopened over-the-counter packaging.  Students cannot carry their own medications to the health office. Please bring no more than a 30 day supply at a time.  More information about medication administration at school is available online within Pine Island Public School Board Policy 516 Student Medication.

SCHOOL HEALTH INFORMATION FORM: 
This form should be completed for all students in Pine Island Public Schools grade Kindergarten, 3rd, 6th, 9th.  It is also need for all students that are new to the district.  This form should also be completed for students that are being evaluated for special education or 504 plans.

DIETARY GUIDELINES: ALLERGIES &; INTOLERANCES (Grades PreK-4th)
This form provides guidelines for managing a student’s food allergy/intolerance to appropriate staff members (e.g. nursing, dietary,classroom teacher(s), special areas).  Form is valid for grades PreK through 4th grade only.

ANAPHYLAXIS EMERGENCY CARE PLAN:  
This form gives the school authorization to administer epinephrine(e.g.EpiPen, Auvi-Q) to a child during an anaphylactic reaction(life-threatening allergic reaction) during the school day.


SEIZURE EMERGENCY CARE PLAN
This form should be completed for students that have a seizure disorder.

DIABETES MEDICAL MANAGEMENT PLAN (DMMP) 
DIABETES INSULIN THERAPY: BASE DOSAGES & CORRECTION SCALE:   

These forms should be completed for a student with diabetes. 
An Authorization for Medication Administration Form or a written order signed by a physician for medications (e.g. insulin, glucagon) is also required. 

Parents are responsible to bring all diabetic supplies (e.g. test strips,meter, insulin, needles, syringe, glucagon, snacks, glucose tabs, ketone strips) to the health office prior to the beginning of the school year.

CONSENT TO RELEASE PRIVATE DATA
To exchange information with an outside agency regarding your child’s emergency care plan(s) or medical condition(s).  This form is requested of all children with emergency care plan(s) or medical condition(s).  

ASTHMA ACTION PLANS
Asthma Action Plans need to be completed for students with asthma. This form will give authorization for asthma medications to be given at school.  Asthma Action Plans can be requested from your Health Care Provider.  It is electronically signed by a physician and is good for a year from that signature date.


Completed forms can be emailed to Kpokrandt@pineisland.k12.mn.us or Faxed to 507.356.4130