Minnesota Guidelines for Medication Administration in Schools - May 2005

(Updated: September 2005)

Maternal and Child Health Section graphic of an outline of a parent with a child in the middle of the outline of Minnesota.

Appendix H: Sample Forms

Authorization Forms

H.1: Burnsville/Eagan/Savage Schools Medication/Treatment Authorization Form (PDF: 54 KB/2 pages) | (MS Word: 38 Kb/2 pages)

H.2: Edina Public Schools Health Services - Administration of Medication During the School Day (PDF: 61 KB/1 page) | (MS Word: 25 KB/1 page)

H.3: Rochester Catholic Schools - Physician Order for Medication and Parent/Guardian Authorization Form (PDF: 57 KB/2 pages) | (MS Word: 18 KB/2 pages)

H.4: Rochester Catholic Schools - Over-the-Counter Medication Authorization of Administration of Medication (PDF: 52 KB/2 pages) | (MS Word: 29 KB/2 pages)

Error/Occurrence Form

H.5: Medication Occurrence/Error Report (PDF: 47 KB/1 page) | (MS Word: 39 KB/1 page)

Field Trip Forms

H.6: Parent/Legal Guardian Health/Emergency Permission Slip for Field Trips (PDF: 55 KB/1 page) | (MS Word: 21 KB/1 page)

H.7: Field Trip Medication Administration Procedure (PDF: 54 KB/2 pages) | (MS Word: 30 KB/2 pages)

H.8: Field Trip Medication Administration Training & Skills Check List (PDF: 59 KB/2 pages) | (MS Word: 32 KB/2 pages)

Health Plan Forms

H.9: Individual Health Plan (PDF: 33 KB/1 page) | (MS Word: 20 KB/1 page)

H.10: Medication Administration Plan and/or Student Medication Self Carry/Self Administration Plan (PDF: 38 KB/1 page) | (MS Word: 22 KB/1 page)

H.11: Emergency Care Plan (PDF: 45 KB/2 pages) | (MS Word: 23 KB/2 pages)

H.12: Emergency Information Form for Children with Special Needs (PDF: 106 KB/2 pages) | (MS Word: 279 KB/2 pages)

H.13: Individual Health Plan Resources (PDF: 53 KB/1 page) | (MS Word: 25 KB/1 page)

Self Administration Forms

H.14: Self-Administration of Medication Authorization (PDF: 51 KB/1 page) | (MS Word: 23 KB/1 page)

H.15: Rochester Catholic Schools - Self-Administration of Medication Authorization (PDF: 63 KB/2 pages) | (MS Word: 31 KB/2 pages)

H.16: Self Carried/Self Administered Medication Agreement & Evaluation Form (PDF: 53 KB/1 page) | (MS Word: 22 KB/1 page)

H.17: Authorization to Carry Self-Administration of Medication (PDF: 42 KB/1 page) | (MS Word: 26 KB/1 page)

Single Purpose/Miscellaneous Forms

H.18: Medication Administration Skills Check List (PDF: 56 KB/2 pages) | (MS Word: 51 KB/2 pages)

H.19: Parent/Legal Guardian Letter (PDF: 49 KB/1 page) | (MS Word: 22 KB/1 page)

H.20: Verbal Medication Consent Form (PDF: 51 KB/1 page) | (MS Word: 21 KB/1 page)

H.21: Receipt for Medication (PDF: 44 KB/1 page) | (MS Word: 20 KB/1 page)

H.22: Student Medication Count Log (PDF: 44 KB/1 page) | (MS Word: 38 KB/1 page)

H.23: Left Over Medications Parent Letter (PDF: 48 KB/1 page) | (MS Word: 20 KB/1 page)

H.24: Certificate of Inventory and Distribution of Medications (PDF: 26 KB/1 page) | (MS Word: 43 KB/1 page)

H.25: Medication Administration Record (PDF: 59 KB/2 pages) | (MS Word: 99 KB/2 pages)


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