Medication Forms | Letters | Notifications (Includes Medication on Field Trips)
Administration/Use Tracking Forms
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.
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).
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
Diabetes Medication Tracking Forms
Blood Glucose / Insulin Log for Individual Students (NYSDOH Guide-Page 94)
Field Trip Forms
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)
Receipt Forms for Medications / Expiration of Medication Form / Medication Error
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 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)