Authorization or Airway Constricting Medication Self-Administration Consent Form

Code No. 504.4E1
AUTHORIZATION ASTHMA OR AIRWAY CONSTRICTING MEDICATION
SELF-ADMINISTRATION CONSENT FORM
_____________________________ ___/___/___ _________________ ___/___/___
Student’s Name (Last), (First) (Middle) Birthday School Date
In order for a student to self-administer medication for asthma or any airway constricting disease:
 Parent/guardian provides signed, dated authorization for student medication self-administration.
 Physician (person licensed under chapter 148, 150, or 150A, physician, physician’s assistant,
advanced registered nurse practitioner, or other person licensed or registered to distribute or
dispense a prescription drug or device in the course of professional practice in Iowa in accordance
with section 147.107, or a person licensed by another state in a health field in which, under Iowa
law, licensees in this state may legally prescribe drugs) provides written authorization containing:
o purpose of the medication,
o prescribed dosage,
o times or;
o special circumstances under which the medication is to be administered.
 The medication is in the original, labeled container as dispensed or the manufacturer’s labeled
container containing the student name, name of the medication, directions for use, and date.
 Authorization is renewed annually. If any changes occur in the medication, dosage or time of
administration, the parent is to notify school officials immediately. The authorization shall be
reviewed as soon as practical.
Provided the above requirements are fulfilled, a student with asthma or other airway constricting disease
may possess and use the student’s medication while in school, at school-sponsored activities, under the
supervision of school personnel, and before or after normal school activities, such as while in beforeschool
or after-school care on school-operated property. If the student abuses the self-administration
policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed.
Pursuant to state law, the school district or accredited nonpublic school and its employees are to incur no
liability, except for gross negligence, as a result of any injury arising from self-administration of
medication by the student. The parent or guardian of the student shall sign a statement acknowledging
that the school district or nonpublic school is to incur no liability, except for gross negligence, as a result
of self-administration of medication by the student as established by IOWA CODE § 280.16.
Medication Dosage Route Time
Purpose of Medication & Administration /Instructions
AUTHORIZATION-ASTHMA OR AIRWAY CONSTRICTING MEDICATION
SELF-ADMINISTRATION CONSENT FORM
/ /
Special Circumstances Discontinue/Re-Evaluate/
Follow-up Date
/ /
Prescriber’s Signature Date
Prescriber’s Address Emergency Phone
 I request the above named student possess and self-administer asthma or other airway constricting
disease medication(s) at school and in school activities according to the authorization and
instructions.
 I understand the school district and its employees acting reasonably and in good faith shall incur
no liability for any improper use of medication or for supervising, monitoring, or interfering with
a student’s self-administration of medication
 I agree to coordinate and work with school personnel and notify them when questions arise or
relevant conditions change.
 I agree to provide safe delivery of medication and equipment to and from school and to pick up
remaining medication and equipment.
 I agree the information is shared with school personnel in accordance with the Family Education
Rights and Privacy Act (FERPA).
 I agree to provide the school with back-up medication approved in this form.
 (Student maintains self-administration record if appropriate.)
/ /
Parent/Guardian Signature Date
(agreed to above statement)
Parent/Guardian Address Home Phone
Business Phone
Self-Administration Authorization Additional Information
Approved 2/2/15