Medication Forms | Letters | Notifications (Includes Medication on Field Trips)

Please see Care Plans (AAP, ECP. DMMP) | Diabetes Addendum | Flow Sheets | IHP, 504 for additions forms related to Medication.  

Administration/Use Tracking Forms

Daily Medication Record School Year (Excel format) - Calendar view of medication charting for an individual student modifiable for your school district. Revised 6/18

Dose Counting Daily Medication Record (Excel format) - Calendar view record of medication administration which provides a continuous count of medication given and medication remaining. Revised 7/2018.

Dose Counting Daily Medication Record  School Year (PDF format) - Calendar view record of medication administration which provides a continuous count of medication given and medication remaining. Revised 7/2018.

Daily Medication Sheet For Summer School - July and August calendar view of medication charting. Revised 7/18

Monthly Medication Administration Record (Medicaid Compliant) - Records date, times, doses, exception codes, reactions, Medicaid compliant signature boxes and NPI number.

Authorization / Permission Forms

Attestation/Independent Medication Carry and Use Permission with Provider Attestation and Parents/Guardians Permission. Allows the provider to document the diagnosis and attestation for a student to carry and use their medication independently as required by NYS law. It may be used as an addendum to a medication order which does not contain these required elements (Revised 9/2017).

Attestation: Sample Letter to Parents/Guardians - Informs parents and guardians about the attestation requirements (9/2017)

Attestation: Sample Letter to Local Health Care Providers -Informs local health care providers about the new attestation requirements (9/2017)

Diabetes Medical Management Plan Addendum: Role of Parents/Guardians in Adjustment of Insulin Dose Documents provider permission to allow parents/guardians to adjust insulin dose. (5/2017)

Guidance for Students to Independently Carry and Use Medication at School - NYS law requires private HCPs provide attestation of a student's ability to independently carry and use their medication in school. This guidance details on how schools can implement this law (9/2017).

Parent/Guardian & Health Care Provider Permission to Administer Medication - Documents provider order & parent permission for medication use at school. It does not indicate allow permission for the student to carry and use the medication independently. Additional permission from the provider and parent for Independent Medication Carry and Use must also be completed for that to occur (12/2017)

Determining Who Can Administer Medication and Students Capability

Levels of Assistance in Administering Medications Guide-Provides guidance in determining how may and may not administer medications in school and the how to determine who may do so. (Updated 8-16)

Diabetes Medication Tracking Forms

Blood Glucose / Insulin Log for Individual Students  (NYSDOH Guide-Page 94)

Diabetes Medical Management Plan Addendum: Role of Parents/Guardians in Adjustment of Insulin Dose 5/2017

Field Trip Forms

Field Trip Medication Record for Licensed Professionals Administering Medication- Documents medication delivery by licensed professionals for students on field trips. (12/16)

Field Trip Medication Record for Unlicensed Professionals Assisting Self-Directed Students with Administration of Medication - Documents medication taken by students supervised by unlicensed professionals on field trips. (12/16)

Parent/Guardian Permission for Field Trip Attendance and Medication Delivery - Documents field trip information and parent/guardian permission for administration of medications. Provider attestation must be included for independent medication use.

School Checklist for Medications on Field Trips - Checklist of responsibilities regarding medications administration on field trips for the School Board/Administration, School Nurse/District Personnel, Parent/Student.  Includes options for provision of medication to students who require medication on field trips.  (12/16) 

Sample Field Trip Notification with Information for Parents on Insect Repellents (NYSCSH May 2018)

Receipt Forms for Medications / Expiration of Medication Form / Medication Error

Receipt of Medication Delivered to School - Documents receipt of initial and subsequent medication delivery from parents.

Receipt of Medication Returned to Parent/Guardian - Documents the return of medication from the Health Office to the parent/guardian.

Expiration of Medication Recording Form - Documents students name, teacher/grade, medication name and expiration date.

Medication Incident Report Form - Documents medication error, notifications made, and outcome.

Sunscreen

Sample Sunscreen Parent Permission for students who can independently apply or with adult assistance to help apply their own or school provided sunscreen.

Training & Self Determination Forms and Checklists

Checklist Training Unlicensed Personnel to Assist Supervised Students in Taking Their Own Medications - Checklist of training criteria for unlicensed assistive personnel to assist supervised (self-directed) students in taking their own medications (10/15)

Nursing Assessment for Determination of Supervised (formerly Self-Directed) Student - This is a customizable version of the above document.  This lists the steps to go through in determination of supervised student (10/15)

Parent/Guardian Medication Communications & Notification

Medication Delivery Note to parents/guardians - Medication delivery information for bringing medications to school

End of Year Pick Up - Medication pick up information for end of year

Parent/Guardian Permission for Field Trip Attendance and Medication Delivery - Documents field trip information and parent/guardian permission for administration of medications 

Parent/Guardian Designation to Authorize Another Adult to Administer Medication - Documents parent/guardian permission to authorize another adult to administer medication to their child for a specific event. (Updated 1/2018) 

Sample Letter to Parents/Guardians Regarding Attestation for Independent Carry and Use of Medication-Informs parents and guardians about the new attestation requirements. (8/15)

Updated 8/3/18