LICKING HEIGHTS	LOCAL SCHOOLS

SELF MEDICATION FOR ASTHMA-INHALERS AUTHORIZATION FORM

Student Name:_____________________________________________ Grade:_____________ Address:_____________________________________________________________________ Medication Name:______________________________________________________________ Dosage:_____________________________________________________________________ Date to begin administration:__________________Date to end administration:______________ Adverse reactions that should be reported to the physician:_____________________________ ____________________________________________________________________________ Procedure to follow in the event that medication does not produce the expected relief from the student’s asthma attack:_________________________________________________________ ____________________________________________________________________________

By signing below the physician or other health care provide and parent/guardian state that it is their request that the child carry the inhaler on their person at school and at school functions; they realize that because the student is self-administering medication, no adult may be aware that the student is experiencing difficulty, preventing adults from responding appropriately in an emergency and that the child has been fully trained in the use of the inhaler, knows why, how and when to use it properly and will not give the inhaler to any other students.

Physician name:__________________________________________Phone:_______________ Signature:_______________________________________________Phone:_______________ Parent/Guardian name:____________________________________Phone:________________ Signature:_______________________________________________Date:_________________

In the event that the metered doses inhaler is abused or misused by the student or others, school personnel have the responsibility to assume control of the inhaler and contact the parent/guardian to assess the next best action for the student, classmates and others.

Nurse’s signature:__________________________________________ Date:_______________