Health Services
Documents and Forms
| Diabetes Dr's. Order Form | English |
Spanish |
| Epi-Pen Order Form | English |
Spanish |
| Guidelines for Administration of Medication | English |
Spanish |
| Immunization Requirements | More Info |
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| Inhaler Self-Medication Authorization Parent & Physician Permissions | English |
Spanish |
| Insulin Pump Diabetes Order Form | English |
Spanish |
| Management of Life Threatening Health Conditions | English |
Spanish |
| Parent Authorization for the Administration of Medications | English |
Spanish |
| Permission to Self-Administer Independently | English |
Spanish |
| Physician's Order for Gastrostomy Feeding | English |
Spanish |
| Physician's Rectal Valium Order Form | English |
Spanish |
| Student Medication Log | English |
Spanish |
Epinephrine Use
Section 1002.20 (i) Florida Statute states: a student who has experienced or is at risk for life-threatening allergic reactions may carry an epinephrine auto-injector and self-administer epinephrine by auto-injector while in school, participating in school-sponsored activities, or in transit to or from school or school-sponsored activities if the school has been provided with parental/guardian and physician, advanced registered nurse practitioner or physician assistant authorization. The parent or guardian of a student authorized to carry an epinephrine autoinjector must complete permission forms annually which eliminates any and all liability with respect to the student’s use of an epinephrine auto-injector. The physician, physician assistant, or advanced registered nurse practitioner must complete permission forms annually attesting the student is able to recognize the signs and symptoms and manage their life-threatening allergies (ss.Chapters 464, 458, and 459).
Inhaler Use
Asthmatic students may carry a metered dose inhaler while in school with written permission from their parent/guardian and physician, advanced registered nurse practitioner, or physician assistant (Section 1002.20 (h) Florida Statute) (ss.Chapters 464, 458, and 459). The permission to self-carry inhaler forms must be completed by the parent and the physician, advanced registered nurse practitioner or physical assistant.
Management of Life-Threatening Health Conditions
A student may be permitted to self-administer medication for potentially life-threatening illnesses such as diabetes, allergies, asthma, and cystic fibrosis. Guidelines for this process are based on F.S. 1002.20(3) (h)-(k). Written authorization is needed from the student’s physician, advanced registered nurse practitioner, or physician assistant certifying that the student has the life-threatening illness. In addition, the licensed health care provider is attesting that the student is capable of and has been instructed in the proper administration of the required medicine and/or procedure for management of life-threatening health condition(s). Also, the parent/guardian must sign a written authorization for their child to self-administer medication. This authorization also includes a statement that the school district shall incur no liability as a result of any injury arising from the self-administration. The permission is effective for the school year and will be reviewed annually. Please note that permission may be revoked if there is reason to believe that the life-sustaining medication, treatment, equipment or supplies are being used inappropriately. Parent/guardian should contact the clinic at their child’s school site for appropriate paperwork.
