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.
Administration Authorization / Permission Forms
Administration of Medication at School-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 (3/2019)
Attestation Sample Form - This form may be used as an addendum along with provider order and parent/guardian permission for students to carry and use medications that require rapid administration. (9/2017)
Sample Provider and Parent Guardian Permission for the use of School Provided Spacer/Valved Holding ChamberProvides schools the opportunity to provide a back-up spacer in the event that the student's is not available. (7/7/20)
Determining Who Can Administer Medication and Students Capability
Diabetes Medication 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 the administration of medications. Provider attestation must be included for independent medication use.
School Checklist for Medications on Field Trips - Checklist of responsibilities regarding medication administration on field trips for the School Board/Administration, School Nurse/District Personnel, Parent/Student. Includes options for the provision of medication to students who require medication on field trips. (12/16)
Parent/Guardian Medication Communications & Notification
Sample Medication Delivery Information for Parents- Provides information for Parents/Guardians on what is needed to administer medications at school, including recommendations for a spacer for MDI use vs. nebulizer. (7/7/20)
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)
Receipt Forms for Medications / Expiration of Medication Form / Documentation of Medication Errors
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)
Page updated 1/22/2021