Colchester, Connecticut

5141.21P Administration of Medication

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5141.21P
                                                                          STUDENTS


         ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS
                       DRAFT January 2022 - First Reading 1/26/2022
                        Additional Language on Naloxone From S&G


A.   Definitions

     Administration of medication means any one of the following activities: handling,
     storing, preparing or pouring of medication; conveying it to the student
     according to the medication order; observing the student inhale, apply, swallow,
     or self-inject the medication, when applicable; documenting that the medication
     was administered; and counting remaining doses to verify proper administration
     and use of the medication.

     Authorized prescriber means a physician, dentist, optometrist, advanced practice
     registered nurse or physician assistant, and, for interscholastic and intramural
     athletic events only, a podiatrist.

     Before or After School Program means any child care program operated and
     administered by a local or regional board of education exempt from licensure by
     the Office of Early Childhood pursuant to subdivision (1) of subsection (b) of
     Section 19a-77 of the Connecticut General Statutes. Such programs do not
     include public or private entities licensed by the Office of Early Childhood or
     board of education enhancement programs and extra-curricular activities.

     Cartridge Injector means an automatic prefilled cartridge injector or similar
     automatic injectable equipment used to deliver epinephrine in a standard dose
     for emergency first aid response to allergic reactions.

     Coach means any person holding a coaching permit who is hired by a local or
     regional board of education to coach for a sport season.

     Controlled drugs means those drugs as defined in Conn. Gen. Stat. Section 21a-



                       ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS           Page 1 of 33
240.
Cumulative health record means the cumulative health record of a pupil
mandated by Conn. Gen. Stat. Section 10-206.
Director means the person responsible for the day-to-day operations of any
school readiness program or before-and-after school program.

Eligible student means a student who has reached the age of eighteen or is an
emancipated minor.

Error means:

(1)    the failure to do any of the following as ordered:

       (a)     administer a medication to a student;
       (b)     administer medication within the time designated by the
               prescribing physician;
       (c)     administer the specific medication prescribed for a
               student;
       (d)     administer the correct dosage of medication;
       (e)     administer medication by the proper route;
       (f)     administer the medication according to generally accepted
               standards of practice; or

(2)    the administration of medication to a student which is not ordered, or
       which is not authorized in writing by the parent or guardian of such
       student, except for the administration of epinephrine or naloxone for the
       purpose of emergency first aid as set forth in Sections D and E below.

Guardian means one who has the authority and obligations of guardianship of
the person of a minor, and includes: (1) the obligation of care and control; and
(2) the authority to make major decisions affecting the minor's welfare,
including, but not limited to, consent determinations regarding marriage,
enlistment in the armed forces and major medical, psychiatric or surgical
treatment.

Intramural athletic events means tryouts, competition, practice, drills, and
transportation to and from events that are within the bounds of a school district
for the purpose of providing an opportunity for students to participate in



                   ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 2 of 33
physical activities and athletic contests that extend beyond the scope of the
physical education program.

Interscholastic athletic events means events between or among schools for the
purpose of providing an opportunity for students to participate in competitive
contests that are highly organized and extend beyond the scope of intramural
programs and includes tryouts, competition, practice, drills and transportation to
and from such events.

Investigational drug means any medication with an approved investigational new
drug (IND) application on file with the Food and Drug Administration (FDA),
which is being scientifically tested and clinically evaluated to determine its
efficacy, safety and side effects and which has not yet received FDA approval.

Licensed athletic trainer means a licensed athletic trainer employed by the
school district pursuant to Chapter 375a of the Connecticut General Statutes.

Medication means any medicinal preparation, both prescription and non-
prescription, including controlled drugs, as defined in Conn. Gen. Stat. Section
21a-240. This definition includes Aspirin, Ibuprofen or Aspirin substitutes
containing Acetaminophen.

Medication Emergency means a life-threatening reaction of a student to a
medication.

Medication plan means a documented plan established by the school nurse in
conjunction with the parent and student regarding the administration of
medication in school. Such plan may be a stand-alone plan, part of an
individualized health care plan, an emergency care plan or a medication
administration form.

Medication order means the authorization by an authorized prescriber for the
administration of medication to a student which shall include the name of the
student, the name and generic name of the medication, the dosage of the
medication, the route of administration, the time of administration, the
frequency of administration, the indications for medication, any potential side
effects including overdose or missed dose of the medication, the start and
termination dates not to exceed a 12-month period, and the written signature of
the prescriber.


                   ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 3 of 33
Nurse means an advanced practice registered nurse, a registered nurse or a
practical nurse licensed in Connecticut in accordance with Chapter 378, Conn.
Gen. Stat.

Occupational Therapist means an occupational therapist employed full time by
the local or regional board of education and licensed in Connecticut pursuant to
Chapter 376a of the Connecticut General Statutes.

Optometrist means an optometrist licensed to provide optometry pursuant to
Chapter 380 of the Connecticut General Statutes.

Paraprofessional means a health care aide or assistant or an instructional aide or
assistant employed by the local or regional board of education who meets the
requirements of such board of employment as a health care aide or assistant or
instructional aide or assistant.

Physical therapist means a physical therapist employed full time by the local or
regional board of education and licensed in Connecticut pursuant to Chapter 376
of the Connecticut General Statutes.

Physician means a doctor of medicine or osteopathy licensed to practice
medicine in Connecticut pursuant to Chapters 370 and 371 of the Connecticut
General Statutes, or licensed to practice medicine in another state.

Podiatrist means an individual licensed to practice podiatry in Connecticut
pursuant to Chapter 375 of the Connecticut General Statutes.

Principal means the administrator in the school.

Research or study medications means FDA-approved medications being
administered according to an approved study protocol. A copy of the study
protocol shall be provided to the school nurse along with the name of the
medication to be administered and the acceptable range of dose of such
medication to be administered.

School means any educational facility or program which is under the jurisdiction
of the Board excluding extracurricular activities.
School nurse means a nurse appointed in accordance with Conn. Gen. Stat.



                  ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS             Page 4 of 33
     Section 10-212.

     School nurse supervisor means the nurse designated by the local or regional
     board of education as the supervisor or, if no designation has been made by the
     board, the lead or coordinating nurse assigned by the board.

     School readiness program means a program that receives funds from the State
     Department of Education for a school readiness program pursuant to subsection
     (b) of Section 10-16p of the Connecticut General Statutes and exempt from
     licensure by the Office of Early Childhood pursuant to subdivision (1) of
     subsection (b) of Section 19a-77 of the Connecticut General Statutes.

     Self-administration of medication means the control of the medication by the
     student at all times and is self-managed by the student according to the
     individual medication plan.

     Teacher means a person employed full time by the Board who has met the
     minimum standards as established by the Board for performance as a teacher
     and has been approved by the school medical advisor and school nurse to be
     designated to administer medications pursuant to the Regulations of
     Connecticut State Agencies Sections 10-212a-1 through 10-212a-7.

B.   General Policies On Administration of Medications

     (1)    Except as provided below in Section D, no medication, including non-
            prescription drugs, may be administered by any school personnel
            without:

            (a)    the written medication order of an authorized prescriber;
            (b)    the written authorization of the student's parent
                   or guardian or eligible student; and
            (c)    the written permission of a parent for the exchange of
                   information between the prescriber and the school nurse
                   necessary to ensure safe administration of such medication.

     (2)    Prescribed medications shall be administered to and taken by only the
            person for whom the prescription has been written.

     (3)    Except as provided in Section D, medications may be administered only



                       ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 5 of 33
by a licensed nurse or, in the absence of a licensed nurse, by:

(a)    a full-time principal, a full-time teacher, or a full-time licensed
       physical or occupational therapist employed by the school district.
       A full-time principal, teacher, licensed physical or occupational
       therapist employed by the school district may administer oral,
       topical, intranasal or inhalant medications. Such individuals may
       administer injectable medications only to a student with a
       medically diagnosed allergic condition that may require prompt
       treatment to protect the student against serious harm or death.

(b)    students with chronic medical conditions who are able to possess,
       self-administer, or possess and self-administer medication,
       provided all of the following conditions are met:

       (i)        an authorized prescriber provides a written medication
                  order, including the recommendation for possession, self-
                  administration, or possession and self-administration;

       (ii)       there is a written authorization for possession, self-
                  administration, or possession and self-administration from
                  the student's parent or guardian or eligible student;

       (iii)      the school nurse has developed a plan for possession, self-
                  administration, or possession and self-administration, and
                  general supervision, and has documented the plan in the
                  student’s cumulative health record;

       (iv)       the school nurse has assessed the student’s competency
                  for self-administration and deemed it safe and
                  appropriate, including that the student: is capable of
                  identifying and selecting the appropriate medication by
                  size, color, amount or other label identification; knows the
                  frequency and time of day for which the medication is
                  ordered; can identify the presenting symptoms that
                  require medication; administers the medication
                  appropriately; maintains safe control of the medication at
                  all times; seeks adult supervision whenever warranted;
                  and cooperates with the established medication plan;


               ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 6 of 33
      (v)        the principal, appropriate teachers, coaches and other
                 appropriate school personnel are informed the student is
                 possessing, self-administering, or possessing and self-
                 administering prescribed medication;

      (vi)       such medication is transported to school and maintained
                 under the student's control in accordance with this policy;
                 and

      (vii)      controlled drugs, as defined in this policy, may not be
                 possessed or self-administered by students, except in
                 extraordinary situations, such as international field trips,
                 with approval of the school nurse supervisor and the
                 school medical advisor in advance and development of an
                 appropriate plan.

(c)   a student diagnosed with asthma who is able to self-administer
      medication shall be permitted to retain possession of an
      asthmatic inhaler at all times while attending school, in order to
      provide for prompt treatment to protect such child against serious
      harm or death, provided all of the following conditions are met:

      (i)        an authorized prescriber provides a written order
                 requiring the possession of an inhaler by the student at all
                 times in order to provide for prompt treatment in order to
                 protect the child against serious harm or death and
                 authorizing the student’s self-administration of
                 medication, and such written order is provided to the
                 school nurse;

      (ii)       there is a written authorization from the student's parent
                 or guardian regarding the possession of an inhaler by the
                 student at all times in order to protect the child against
                 serious harm or death and authorizing the student’s self-
                 administration of medication, and such written
                 authorization is provided to the school nurse;

      (iii)      the conditions set forth in subsection (b) above have been


              ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 7 of 33
                 met, except that the school nurse’s review of a student’s
                 competency to self-administer an inhaler for asthma in the
                 school setting shall not be used to prevent a student from
                 retaining and self-administering an inhaler for asthma.
                 Students may self-administer medication with only the
                 written authorization of an authorized prescriber and
                 written authorization from the student’s parent or
                 guardian or eligible student; and

      (iv)       the conditions for self-administration meet any regulations
                 as may be imposed by the State Board of Education in
                 consultation with the Commissioner of Public Health.

(d)   a student diagnosed with an allergic condition who is able to self-
      administer medication shall be permitted to retain possession of a
      cartridge injector at all times while attending school, in order to
      provide for prompt treatment to protect such child against serious
      harm or death, provided all of the following conditions are met:

      (i)        an authorized prescriber provides a written order
                 requiring the possession of a cartridge injector by the
                 student at all times in order to provide for prompt
                 treatment in order to protect the child against serious
                 harm or death and authorizing the student’s possession,
                 self-administration, or possession and self-administration
                 of medication, and such written order is provided to the
                 school nurse;

      (ii)       there is a written authorization from the student’s parent
                 or guardian regarding the possession of a cartridge
                 injector by the student at all times in order to protect the
                 child against serious harm or death and authorizing the
                 student’s possession, self-administration, or possession
                 and self-administration of medication, and such written
                 authorization is provided to the school nurse;

      (iii)      the conditions set forth in subsection (b) above have been
                 met, except that the school nurse’s review of a student’s
                 competency to self-administer cartridge injectors for


              ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS              Page 8 of 33
                medically-diagnosed allergies in the school setting shall
                not be used to prevent a student from retaining and self-
                administering a cartridge injector for medically-diagnosed
                allergies. Students may self-administer medication with
                only the written authorization of an authorized prescriber
                and written authorization from the student’s parent or
                guardian or eligible student; and

      (iv)      the conditions for self-administration meet any regulations
                as may be imposed by the State Board of Education in
                consultation with the Commissioner of Public Health.

(e)   a student with a medically diagnosed life-threatening allergic
      condition may possess, self-administer, or possess and self-
      administer medication, including but not limited to medication
      administered with a cartridge injector, to protect the student
      against serious harm or death, provided the following conditions
      are met:

      (i)       the parent or guardian of the student has provided written
                authorization for the student to possess, self-administer,
                or possess and self-administer such medication; and

      (ii)      a qualified medical professional has provided a written
                order for the possession, self-administration, or possession
                and self-administration.

(f)   a coach of intramural or interscholastic athletic events or licensed
      athletic trainer who has been trained in the administration of
      medication, during intramural or interscholastic athletic events,
      may administer inhalant medications prescribed to treat
      respiratory conditions and/or medication administered with a
      cartridge injector for students with medically diagnosed allergic
      conditions which may require prompt treatment to protect the
      student against serious harm or death, provided all of the
      following conditions are met:

      (i)       the school nurse has determined that a self-administration
                plan is not viable;


             ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 9 of 33
      (ii)       the school nurse has provided to the coach a copy of the
                 authorized prescriber’s order and parental permission
                 form;

      (iii)      the parent/guardian has provided the coach or licensed
                 athletic trainer with the medication in accordance with
                 Section K of this policy, and such medication is separate
                 from the medication stored in the school health office for
                 use during the school day; and

      (iv)       the coach or licensed athletic trainer agrees to the
                 administration of emergency medication and implements
                 the emergency care plan, identified in Section H of this
                 policy, when appropriate.

(g)   an identified school paraprofessional who has been trained in the
      administration of medication, provided medication is
      administered only to a specific student in order to protect that
      student from harm or death due to a medically diagnosed allergic
      condition, except as provided in Section D below, and the
      following additional conditions are met:

      (i)        there is written authorization from the student's
                 parents/guardian to administer the medication in school;

      (ii)       medication is administered pursuant to the written order
                 of (A) a physician licensed under chapter 370 of the
                 Connecticut General Statutes, (B) an optometrist licensed
                 to practice optometry under chapter 380 of the
                 Connecticut General Statutes, (C) an advanced practice
                 registered nurse licensed to prescribe in accordance with
                 section 20-94a of the Connecticut General Statutes, or (D)
                 a physician assistant licensed to prescribe in accordance
                 with section 20-12d of the Connecticut General Statutes;

      (iii)      medication is administered only with approval by the
                 school nurse and school medical advisor, if any, in
                 conjunction with the school nurse supervisor and under


             ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS           Page 10 of 33
                 the supervision of the school nurse;

      (iv)       the medication to be administered is limited to
                 medications necessary for prompt treatment of an allergic
                 reaction, including, but not limited to, a cartridge injector;
                 and

      (v)        the paraprofessional shall have received proper training
                 and supervision from the school nurse in accordance with
                 this policy and state regulations.

(h)   a principal, teacher, licensed athletic trainer, licensed physical or
      occupational therapist employed by the Board, coach or school
      paraprofessional, provided medication is antiepileptic medication,
      including by rectal syringe, administered only to a specific student
      with a medically diagnosed epileptic condition that requires
      prompt treatment in accordance with the student’s individual
      seizure action plan, and the following additional conditions are
      met:

      (i)        there is written authorization from the student’s
                 parents/guardians to administer the medication;

      (ii)       a written order for such administration has been received
                 from the student’s physician licensed under Chapter 370
                 of the Connecticut General Statutes;

      (iii)      the principal, teacher, licensed athletic trainer, licensed
                 physical or occupational therapist employed by the Board,
                 coach or school paraprofessional is selected by the school
                 nurse and school medical advisor, if any, and voluntarily
                 agrees to administer the medication;

      (iv)       the principal, teacher, licensed athletic trainer, licensed
                 physical or occupational therapist employed by the Board,
                 coach or school paraprofessional annually completes the
                 training program established by the Connecticut State
                 Department of Education and the Association of School
                 Nurses of Connecticut, and the school nurse and medical


             ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 11 of 33
                        advisor, if any, have attested, in writing, that such training
                        has been completed; and

             (v)        the principal, teacher, licensed athletic trainer, licensed
                        physical or occupational therapist employed by the Board,
                        coach or school paraprofessional receives monthly reviews
                        by the school nurse to confirm competency to administer
                        antiepileptic medication.

      (i)    a director of a school readiness program or a before or after
             school program, or the director’s designee, provided that the
             medication is administered:

             (i)        only to a child enrolled in such program; and

             (ii)       in accordance with Section L of this policy.

      (j)    a licensed practical nurse, after the school nurse has established
             the medication plan, provided that the licensed practical nurse
             may not train or delegate the administration of medication to
             another individual, and provided that the licensed practical nurse
             can demonstrate one of the following:

             (i)        training in administration of medications as part of their
                        basic nursing program;

             (ii)       successful completion of a pharmacology course and
                        subsequent supervised experience; or

             (iii)      supervised experience in the administration of medication
                        while employed in a health care facility.

(4)   Medications may also be administered by a parent or guardian to his/her
      own child on school grounds.

(5)   Investigational drugs or research or study medications may be
      administered only by a licensed nurse. For FDA-approved medications
      being administered according to a study protocol, a copy of the study
      protocol shall be provided to the school nurse along with the name of the
      medication to be administered and the acceptable range of dose of such


                    ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS             Page 12 of 33
            medication to be administered.

C.   Diabetic Students

     (1)    The Colchester Board of Education (the “Board”) permits blood glucose
            testing by students who have a written order from a physician or an
            advanced practice registered nurse stating the need and capability of
            such student to conduct self-testing.

     (2)    The Board will not restrict the time or location of blood glucose testing by
            a student with diabetes on school grounds who has written authorization
            from a parent or guardian and a written order from a physician or an
            advanced practice registered nurse stating that such child is capable of
            conducting self-testing on school grounds.

     (3)    In the absence or unavailability of the school nurse, select school
            employees may administer medication with injectable equipment used to
            administer glucagon to a student with diabetes that may require prompt
            treatment in order to protect the student against serious harm or death,
            under the following conditions:

            (a)    The student’s parent or guardian has provided written
                   authorization;

                   (iii)   supervised experience in the administration of medication
                           while employed in a health care facility.

     (4)    Medications may also be administered by a parent or guardian to his/her
            own child on school grounds.

     (5)    Investigational drugs or research or study medications may be
            administered only by a licensed nurse. For FDA-approved medications
            being administered according to a study protocol, a copy of the study
            protocol shall be provided to the school nurse along with the name of the
            medication to be administered and the acceptable range of dose of such
            medication to be administered.

C.   Diabetic Students

     (1)    The Colchester Board of Education (the “Board”) permits blood glucose



                       ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS          Page 13 of 33
      testing by students who have a written order from a physician or an
      advanced practice registered nurse stating the need and capability of
      such student to conduct self-testing.

(2)   The Board will not restrict the time or location of blood glucose testing by
      a student with diabetes on school grounds who has written authorization
      from a parent or guardian and a written order from a physician or an
      advanced practice registered nurse stating that such child is capable of
      conducting self-testing on school grounds.

(3)   In the absence or unavailability of the school nurse, select school
      employees may administer medication with injectable equipment used to
      administer glucagon to a student with diabetes that may require prompt
      treatment in order to protect the student against serious harm or death,
      under the following conditions:

      (a)    The student’s parent or guardian has provided written
             authorization;

      (c)    The school employee is selected by either the school nurse or
             principal and is a principal, teacher, licensed athletic trainer,
             licensed physical or occupational therapist employed by a school
             district, coach or school paraprofessional;

      (d)    The school nurse shall provide general supervision to the selected
             school employee;

      (e)    The selected school employee annually completes any training
             required by the school nurse and school medical advisor in the
             administration of medication with injectable equipment used to
             administer glucagon;

      (f)    The school nurse and school medical advisor have attested in
             writing that selected school employee completed the required
             training; and

      (g)    The selected school employee voluntarily agrees to serve as one
             who may administer medication with injectable equipment used
             to administer glucagon to a student with diabetes that may


                ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS           Page 14 of 33
                   require prompt treatment in order to protect the student against
                   serious harm or death.

D.   Epinephrine for Purposes of Emergency First Aid Without Prior Authorization

     (1)    For purposes of this Section D, “regular school hours” means the posted
            hours during which students are required to be in attendance at the
            individual school on any given day.

     (2)    The school nurse shall maintain epinephrine in cartridge injectors for the
            purpose of emergency first aid to students who experience allergic
            reactions and do not have prior written authorization of a parent or
            guardian or a prior written order of a qualified medical professional for
            the administration of epinephrine.
            (a)    The school nurse, in consultation with the school nurse
                   supervisor, shall determine the supply of epinephrine in cartridge
                   injectors that shall be available in the individual school.

            (b)    In determining the appropriate supply of epinephrine in cartridge
                   injectors, the nurse may consider, among other things, the
                   number of students regularly in the school building during the
                   regular school day and the size of the physical building.

     (3)    The school nurse or school principal shall select principal(s), teacher(s),
            licensed athletic trainer(s), licensed physical or occupational therapist(s)
            employed by the Board, coach(es) and/or school paraprofessional(s) to
            maintain and administer the epinephrine in cartridge injectors for the
            purpose of emergency first aid as described in Paragraph (2) above, in the
            absence of the school nurse.

            (a)    More than one individual must be selected by the school nurse or
                   school principal for such maintenance and administration in the
                   absence of the school nurse.

            (b)    The selected personnel, before conducting such administration,
                   must annually complete the training made available by the
                   Department of Education for the administration of epinephrine in
                   cartridge injectors for the purpose of emergency first aid.



                      ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS           Page 15 of 33
       (c)    The selected personnel must voluntarily agree to complete the
              training and administer epinephrine in cartridge injectors for the
              purpose of emergency first aid.

(4)    Either the school nurse or, in the absence of the school nurse, at least
       one of the selected and trained personnel as described in Paragraph (3)
       above shall be on the grounds of each school during regular school hours.

       (a)    The school principal, in consultation with the school nurse
              supervisor, shall determine the level of nursing services and
              number of selected and trained personnel necessary to ensure
              that a nurse or selected and trained personnel is present on the
              grounds of each school during regular school hours.

       (b)    If the school nurse, or a substitute school nurse, is absent or must
              leave school grounds during regular school hours, the school
              nurse, school administrator or designee shall send an email to all
              staff indicating that the selected and trained personnel identified
              in Paragraph (3) above shall be responsible for the emergency
              administration of epinephrine.

 (5)    The administration of epinephrine pursuant to this section must be done
        in accordance with this policy, including but not limited to the
        requirements for documentation and record keeping, errors in
        medication, emergency medical procedures, and the handling, storage
        and disposal of medication, and the Regulations adopted by the
        Department of Education.

 (6)    The parent or guardian of any student may submit, in writing, to the
        school nurse or school medical advisor, if any, that epinephrine shall not
        be administered to such student pursuant to this section.

       (a)    The school nurse shall notify selected and trained personnel of
              the students whose parents or guardians have refused emergency
              administration of epinephrine.

       (b)    The Board shall annually notify parents or guardians of the need
              to provide such written notice.




                 ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 16 of 33
           (7)     Following the emergency administration of epinephrine by selected and
                   trained personnel as identified in this section:

                   (a)    Such emergency administration shall be reported immediately to:

                          (i)        The school nurse or school medical advisor, if any, by the
                                     personnel who administered the epinephrine; and

                          (ii)       The student’s parent or guardian, by the school nurse or
                                     personnel who administered the epinephrine.

                   (b)    A medication administration record shall be:

                          (i)        Submitted to the school nurse by the personnel who
                                     administered the epinephrine as soon as possible, but no
                                     later than the next school day; and

                          (ii)       filed in or summarized on the student’s cumulative health
                                     record, in accordance with Section E of this policy.

E.         Naloxone for Purposes of Emergency First Aid

     (1)     Pursuant to a standing order of the Board’s medical advisor and authorization from
             the Superintendent of Schools, and in accordance with Connecticut law and this
             policy, a school nurse may maintain naloxone, for the purpose of administering
             emergency first aid to students who experience a known or suspected opioid
             overdose.

             (a)     The school nurse, in consultation with the Board’s medical advisor, shall
                     determine the supply of naloxone that shall be maintained in the individual
                     school.

             (b)     The school nurse shall be responsible for the safe storage of naloxone
                     maintained in a school and shall ensure any supply of naloxone maintained is
                     stored in accordance with the manufacturer’s instructions.

             (c)     The school nurse shall be responsible for maintaining an inventory of naloxone
                     maintained in the school, tracking the date(s) of expiration of the supply of
                     naloxone maintained in a school, and, as appropriate, refreshing the supply of
                     naloxone maintained in the school.

     (2)     The school nurse, in consultation with the Superintendent and the building principal,


                                 ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS             Page 17 of 33
             shall provide notice to parents and guardians of the Board’s policies and procedures
             regarding the emergency administration of naloxone in the event of a known or
             suspected opioid overdose.

     (3)     A school nurse shall be approved to administer naloxone for the purpose of
             emergency first aid, as described in Paragraph (1) above, in the event of a known or
             suspected opioid overdose, provided that such nurse has completed appropriate
             training, as identified by the Board’s medical advisor, which shall include training in
             the identification of opioid abuse and overdose.

     (4)     The administration of naloxone pursuant to this section must be effected in
             accordance with this policy and procedures regarding the acquisition, maintenance,
             and administration established by the Superintendent in consultation with the Board’s
             medical advisor.

     (5)     Following the emergency administration of naloxone by a school nurse:

             (a)     Such emergency administration shall be reported immediately to:

                     (i)       The Board medical advisor; and

                     (ii)      The Superintendent; and

                     (iii)     The student’s parent or guardian.

             (b)     A medication administration record shall be:

                     (i)       Maintained by the school nurse who administered the naloxone as soon
                               as possible, but no later than the next school day; and

                     (ii)      filed in or summarized on the student’s cumulative health record, in
                               accordance with Section F of this policy.


F.         Documentation and Record Keeping

           (1)     Each school or before-and-after school program and school readiness
                   program where medications are administered shall maintain an individual
                   medication administration record for each student who receives
                   medication during school or program hours. This record shall include the
                   following information:

                   (a)       the name of the student;



                               ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS        Page 18 of 33
      (b)    the student’s state-assigned student identifier (SASID);
      (c)    the name of the medication;
      (d)    the dosage of the medication;
      (e)    the route of the administration,
             (i.e. oral, topical, inhalant, etc.);
      (f)    the frequency of administration;
      (g)    the name of the authorized prescriber;
      (h)    the dates for initiating and terminating the administration of
             medication, including extended-year programs;
      (i)    the quantity received at school and verification by the adult
             delivering the medication of the quantity received;
      (j)    the date the medication is to be reordered (if any);
      (k)    any student allergies to food and/or medication(s);
      (l)    the date and time of each administration or omission, including
             the reason for any omission;
      (m)    the dose or amount of each medication administered;
      (n)    the full written or electronic legal signature of the nurse or other
             authorized school personnel administering the medication; and
      (o)    for controlled medications, a medication count which should be
             conducted and documented at least once a week and co-signed
             by the assigned nurse and a witness.

(2)   All records are either to be made in ink and shall not be altered, or
      recorded electronically in a record that cannot be altered.

(3)   Written orders of authorized prescribers, written authorizations of parent
      or guardian, the written parental permission for the exchange of
      information by the prescriber and school nurse to ensure safe
      administration of such medication, and the completed medication
      administration record for each student shall be filed in the student's
      cumulative health record or, for before-and-after school programs and
      school readiness programs, in the child’s program record.

(4)   Authorized prescribers may make verbal orders, including telephone
      orders, for a change in medication order. Such verbal orders may be
      received only by a school nurse and must be followed by a written order,
      which may be faxed, and must be received within three (3) school days.




                ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 19 of 33
     (5)    Medication administration records will be made available to the
            Department of Education for review until destroyed pursuant to Section
            11-8a and Section 10-212a(b) of the Connecticut General Statutes.

            (a)    The completed medication administration record for non-
                   controlled medications may, at the discretion of the school
                   district, be destroyed in accordance with Section M8 of the
                   Connecticut Record Retention Schedules for Municipalities, so
                   long as it is superseded by a summary on the student health
                   record.

            (b)    The completed medication administration record for controlled
                   medications shall be maintained in the same manner as the non-
                   controlled medications. In addition, a separate medication
                   administration record needs to be maintained in the school for
                   three (3) years pursuant to Section 10-212a(b) of the Connecticut
                   General Statutes.
     (6)    Documentation of any administration of medication by a coach or
            licensed athletic trainer shall be completed on forms provided by the
            school and the following procedures shall be followed:

            (a)    a medication administration record for each student shall be
                   maintained in the athletic offices;

            (b)    administration of a cartridge injector medication shall be reported
                   to the school nurse at the earliest possible time, but no later than
                   the next school day;

            (c)    all instances of medication administration, except for the
                   administration of cartridge injector medication, shall be reported
                   to the school nurse at least monthly, or as frequently as required
                   by the individual student plan; and

            (d)    the administration of medication record must be submitted to the
                   school nurse at the end of each sport season and filed in the
                   student’s cumulative health record.

G.   Errors In Medication Administration



                      ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS          Page 20 of 33
     (1)   Whenever any error in medication administration occurs, the following
           procedures shall apply:

           (a)    the person making the error in medication administration shall
                  immediately implement the medication emergency procedures in
                  this Policy if necessary;

           (b)    the person making the error in medication administration shall in
                  all cases immediately notify the school nurse, principal, school
                  nurse supervisor, and authorized prescriber. The person making
                  the error, in conjunction with the principal, shall also immediately
                  notify the parent or guardian, advising of the nature of the error
                  and all steps taken or being taken to rectify the error, including
                  contact with the authorized prescriber and/or any other medical
                  action(s); and
           (c)    the principal shall notify the Superintendent or
                  the Superintendent's designee.

     (2)   The school nurse, along with the person making the error, shall complete
           a report using the authorized medication error report form. The report
           shall include any corrective action taken.

     (3)   Any error in the administration of medication shall be documented in the
           student's cumulative health record or, for before-and-after school
           programs and school readiness programs, in the child’s program record.

     (4)   These same procedures shall apply to coaches and licensed athletic
           trainers during intramural and interscholastic events, except that if the
           school nurse is not available, a report must be submitted by the coach or
           licensed athletic trainer to the school nurse the next school day.

H.   Medication Emergency Procedures

     (1)   Whenever a student has a life-threatening reaction to administration of a
           medication, resolution of the reaction to protect the student's health and
           safety shall be the foremost priority. The school nurse and the
           authorized prescriber shall be notified immediately, or as soon as
           possible in light of any emergency medical care that must be given to the



                     ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS           Page 21 of 33
           student.

     (2)   Emergency medical care to resolve a medication emergency includes but
           is not limited to the following, as appropriate under the circumstances:

           (a)     use of the 911 emergency response system;
           (b)     application by properly trained and/or certified personnel of
                   appropriate emergency medical care techniques, such as cardio-
                   pulmonary resuscitation;
           (c)     administration of emergency medication in accordance with this
                   policy;
           (d)     contact with a poison control center; and
           (e)     transporting the student to the nearest available emergency
                   medical care facility that is capable of responding to a medication
                   emergency.

     (3)   As soon as possible, in light of the circumstances, the principal shall be
           notified of the medication emergency. The principal shall immediately
           thereafter contact the Superintendent or the Superintendent's designee,
           who shall thereafter notify the parent or guardian, advising of the
           existence and nature of the medication emergency and all steps taken or
           being taken to resolve the emergency and protect the health and safety
           of the student, including contact with the authorized prescriber and/or
           any other medical action(s) that are being or have been taken.

I.   Supervision

     (1)   The school nurse is responsible for general supervision of administration
           of medications in the school(s) to which that nurse is assigned.

     (2)   The school nurse's duty of general supervision includes, but is not limited
           to, the following:

           (a)     availability on a regularly scheduled basis to:

                   (i)       review orders or changes in orders and communicate
                             these to personnel designated to give medication for
                             appropriate follow-up;



                         ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS       Page 22 of 33
      (ii)       set up a plan and schedule to ensure medications are
                 given properly;

      (iii)      provide training to licensed nursing personnel, full-time
                 principals, full-time teachers, full-time licensed physical or
                 occupational therapists employed by the school district,
                 coaches of intramural and interscholastic athletics,
                 licensed athletic trainers and identified paraprofessionals
                 designated in accordance with Section B(3)(g), above,
                 which training shall pertain to the administration of
                 medications to students, and assess the competency of
                 these individuals to administer medication;
      (iv)       support and assist other licensed nursing personnel, full-
                 time principals, full-time teachers, full-time licensed
                 physical or occupational therapists employed by the school
                 district, coaches of intramural and/or interscholastic
                 athletics, licensed athletic trainers and identified
                 paraprofessionals designated in accordance with Section
                 B(3)(g), above, to prepare for and implement their
                 responsibilities related to the administration of specific
                 medications during school hours and during intramural
                 and interscholastic athletics as provided by this policy;

      (v)        provide appropriate follow-up to ensure the
                 administration of medication plan results in desired
                 student outcomes, including providing proper notification
                 to appropriate employees or contractors regarding the
                 contents of such medical plans; and

      (vi)       provide consultation by telephone or other means of
                 telecommunications, which consultation may be provided
                 by an authorized prescriber or other nurse in the absence
                 of the school nurse.

(b)   In addition, the school nurse shall be responsible for:

      (i)        implementing policies and procedures regarding the
                 receipt, storage, and administration of medications;



             ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 23 of 33
                   (ii)       reviewing, on a periodic basis, all documentation
                              pertaining to the administration of medications for
                              students;

                   (iii)      performing observations of the competency of medication
                              administration by full-time principals, full-time teachers,
                              full-time licensed physical or occupational therapists
                              employed by the school district, coaches of intramural
                              and/or interscholastic athletics and licensed athletic
                              trainers in accordance with Section B(3)(f), above, and
                              identified paraprofessionals designated in accordance with
                              Section B(3)(g), above, who have been newly trained to
                              administer medications; and,

                   (iv)       conducting periodic reviews, as needed, with licensed
                              nursing personnel, full-time principals, full-time teachers,
                              full-time licensed physical or occupational therapists
                              employed by the school district, coaches of intramural
                              and/or interscholastic athletics and licensed athletic
                              trainers in accordance with Section B(3(f), above, and
                              identified paraprofessionals designated in accordance with
                              Section B(3)(g), above, regarding the needs of any student
                              receiving medication.

J.   Training of School Personnel

     (1)    Full-time principals, full-time teachers, full-time licensed physical or
            occupational therapists employed by the school district, coaches of
            intramural and/or interscholastic athletics and licensed athletic trainers
            in accordance with Section B(3)(f), above, and identified
            paraprofessionals designated in accordance with Section B(3)(g), above,
            who are designated to administer medications shall at least annually
            receive training in their safe administration, and only trained full-time
            principals, full-time teachers, full-time licensed physical or occupational
            therapists employed by the school district, coaches of intramural and/or
            interscholastic athletics and licensed athletic trainers in accordance with
            Section B(3) (f), above, and identified paraprofessionals designated in
            accordance with Section B(3)(g), above, shall be allowed to administer
            medications.


                          ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS         Page 24 of 33
(2)   Training for full-time principals, full-time teachers, full-time licensed
      physical or occupational therapists employed by the school district,
      coaches of intramural and/or interscholastic athletics and licensed
      athletic trainers in accordance with Section B(3)(f), above, and identified
      paraprofessionals designated in accordance with Section B(3)(g), above,
      shall include, but is not necessarily limited to, the following:

      (a)    the general principles of safe administration of medication;
      (b)    the procedures for administration of medications, including the
             safe handling and storage of medications, and the required
             record-keeping; and

      (c)    specific information related to each student’s medication plan,
             including the name and generic name of the medication,
             indications for medication dosage, routes, time and frequency of
             administration, therapeutic effects of the medication, potential
             side effects, overdose or missed doses of the medication, and
             when to implement emergency interventions.

(3)   The principal(s), teacher(s), licensed athletic trainer(s), licensed physical
      or occupational therapist(s) employed by the Board, coach(es) and/or
      school paraprofessional(s) who administer epinephrine as emergency
      first aid, pursuant to Section D above, shall annually complete the
      training program developed by the Departments of Education and Public
      Health and training in cardiopulmonary resuscitation and first aid.

(4)   The Board shall maintain documentation of medication administration
      training as follows:

      (a)    dates of general and student-specific trainings;

      (b)    content of the trainings;

      (c)    individuals who have successfully completed general and student-
             specific administration of medication training for the current
             school year; and

      (d)    names and credentials of the nurse or school medical advisor, if


                ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS             Page 25 of 33
                    any, trainer or trainers.

     (5)    Licensed practical nurses may not conduct training in the administration
            of medication to another individual.

K.   Handling, Storage and Disposal of Medications
     (1)    All medications, except those approved for transporting by students for
            self-medication, those administered by coaches of intramural or
            interscholastic athletics or licensed athletic trainers in accordance with
            Section B(3)(f) above, and epinephrine or naloxone to be used for
            emergency first aid in accordance with Sections D and E above, must be
            delivered by the parent, guardian, or other responsible adult to the nurse
            assigned to the student's school or, in the absence of such nurse, the
            school principal who has been trained in the appropriate administration
            of medication. Medications administered by coaches of intramural or
            interscholastic athletics or licensed athletic trainers must be delivered by
            the parent or guardian directly to the coach or licensed athletic trainer in
            accordance with Section B(3)(f)above.

     (2)    The nurse shall examine on-site any new medication, medication order
            and the required authorization to administer form, and, except for
            epinephrine and naloxone to be used as emergency first aid in
            accordance with Sections D and E above, shall develop a medication
            administration plan for the student before any medication is given to the
            student by any school personnel. No medication shall be stored at a
            school without a current written order from an authorized prescriber.

     (3)    The school nurse shall review all medication refills with the medication
            order and parent authorization prior to the administration of medication,
            except for epinephrine and naloxone intended for emergency first aid in
            accordance with Sections D and E above.

     (4)    Emergency Medications

            (a)     Except as otherwise determined by a student’s emergency care
                    plan, emergency medications shall be stored in an unlocked,
                    clearly labeled and readily accessible cabinet or container in the
                    health room during school hours under the general supervision of
                    the school nurse or, in the absence of the school nurse, the


                      ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 26 of 33
              principal or the principal’s designee who has been trained in the
              administration of medication.
       (b)    Emergency medication shall be locked beyond the regular school
              day or program hours, except as otherwise determined by a
              student’s emergency care plan.

(5)    All medications, except those approved for keeping by students for self-
       medication, shall be kept in a designated and locked location used
       exclusively for the storage of medication. Controlled substances shall be
       stored separately from other drugs and substances in a separate, secure,
       substantially constructed, locked metal or wood cabinet.

(6)    Access to stored medications shall be limited to persons authorized to
       administer medications. Each school or before-and-after school program
       and school readiness program shall maintain a current list of such
       authorized persons.

(7)    All medications, prescription and non-prescription, shall be delivered and
       stored in their original containers and in such a manner that renders
       them safe and effective.

(8)    At least two sets of keys for the medication containers or cabinets shall
       be maintained for each school building or before-and-after school
       program and school readiness program. One set of keys shall be
       maintained under the direct control of the school nurse or nurses and an
       additional set shall be under the direct control of the principal and, if
       necessary, the program director or lead teacher who has been trained in
       the general principles of the administration of medication shall also have
       a set of keys.

(9)    Medications that must be refrigerated shall be stored in a refrigerator at
       no less than 36 degrees Fahrenheit and no more than 46 degrees
       Fahrenheit. The refrigerator must be located in the health office that is
       maintained for health services with limited access. Non-controlled
       medications may be stored directly on the refrigerator shelf with no
       further protection needed. Controlled medication shall be stored in a
       locked box that is affixed to the refrigerator shelf.

(10)   All unused, discontinued or obsolete medications shall be removed from


                 ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS           Page 27 of 33
            storage areas and either returned to the parent or guardian or, if the
            medication cannot be returned to the parent or guardian, the medication
            shall be destroyed in collaboration with the school nurse:

            (a)    non-controlled drugs shall be destroyed in the presence of at least
                   one witness;

            (b)    controlled drugs shall be destroyed in pursuant to Section 21a-
                   262-3 of the Regulations of Connecticut State Agencies; and

            (c)    accidental destruction or loss of controlled drugs must be verified
                   in the presence of a second person, including confirmation of the
                   presence or absence of residue, and jointly documented on the
                   student medication administration record and on a medication
                   error form pursuant to Section 10-212a(b) of the Connecticut
                   General Statutes. If no residue is present, notification must be
                   made to the Department of Consumer Protection pursuant to
                   Section 21a-262-3 of the Regulations of Connecticut State
                   Agencies.

     (11)   Medications to be administered by coaches of intramural or
            interscholastic athletic events or licensed athletic trainers shall be stored:

            (a)    in containers for the exclusive use of holding medications;

            (b)    in locations that preserve the integrity of the medication;

            (c)    under the general supervision of the coach or licensed athletic
                   trainer trained in the administration of medication;       and

            (d)    in a locked secured cabinet when not under the general
                   supervision of the coach or licensed athletic trainer during
                   intramural or interscholastic athletic events.

     (12)   In no event shall a school store more than a three (3) month supply of a
            medication for a student.

L.   School Readiness Programs and Before-and-After School Programs
     (1)    As determined by the school medical advisor, if any, and school nurse


                      ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS              Page 28 of 33
supervisor, the following procedures shall apply to the administration of
medication during school readiness programs and before-and-after
school programs run by the Board, which are exempt from licensure by
the Office of Early Childhood:

(a)    Administration of medication at these programs shall be provided
       only when it is medically necessary for participants to access the
       program and maintain their health status while attending the
       program.

(b)    Except as provided by Sections D and E above, no medication shall
       be administered in these programs without:

       (i)        the written order of an authorized prescriber; and

       (ii)       the written authorization of a parent or guardian or an
                  eligible student.

(c)    A school nurse shall provide consultation to the program director,
       lead teacher or school administrator who has been trained in the
       administration of medication regarding the safe administration of
       medication within these programs. The school medical advisor
       and school nurse supervisor shall determine whether, based on
       the population of the school readiness program and/or before-
       and-after school program, additional nursing services are required
       for these programs.

(d)    Only school nurses, directors or directors’ designees, lead
       teachers or school administrators who have been properly trained
       may administer medications to students as delegated by the
       school nurse or other registered nurse. Properly trained directors
       or directors’ designees, lead teachers or school administrators
       may administer oral, topical, intranasal or inhalant medications.
       Investigational drugs or research or study medications may not be
       administered in these programs.
(e)    Students attending these programs may be permitted to self-
       medicate only in accordance with the provisions of Section B(3) of
       this policy. In such a case, the school nurse must provide the
       program director, lead teacher or school administrator running


              ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS          Page 29 of 33
             the program with the medication order and parent permission for
             self-administration.

      (f)    In the absence of the school nurse during program administration,
             the program director, lead teacher or school administrator is
             responsible for decision-making regarding medication
             administration.

      (g)    Cartridge injector medications may be administered by a director,
             lead teacher or school administrator only to a student with a
             medically-diagnosed allergic condition which may require prompt
             treatment to protect the student against serious harm or death.

(2)   Local poison control center information shall be readily available at these
      programs.

(3)   Procedures for medication emergencies or medication errors, as outlined
      in this policy, must be followed, except that in the event of a medication
      error a report must be submitted by the program director, lead teacher
      or school administrator to the school nurse the next school day.

(4)   Training for directors or directors’ designees, lead teachers or school
      administrators in the administration of medication shall be provided in
      accordance with Section IJ of this policy.

(5)   All medications must be handled and stored in accordance with Section K
      of this policy. Where possible, a separate supply of medication shall be
      stored at the site of the before-and-after or school readiness program. In
      the event that it is not possible for the parent or guardian to provide a
      separate supply of medication, then a plan shall be in place to ensure the
      timely transfer of the medication from the school to the program and
      back on a daily basis.
(6)   Documentation of any administration of medication shall be completed
      on forms provided by the school and the following procedures shall be
      followed:

      (a)    a medication administration record for each student shall be
             maintained by the program;



                ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 30 of 33
               (b)     administration of a cartridge injector medication shall be reported
                       to the school nurse at the earliest possible time, but no later than
                       the next school day;

               (c)     all instances of medication administration, except for the
                       administration of cartridge injector medication, shall be reported
                       to the school nurse at least monthly, or as frequently as required
                       by the individual student plan; and

               (d)     the administration of medication record must be submitted to the
                       school nurse at the end of each school year and filed in the
                       student’s cumulative health record.

       (7)     The procedures for the administration of medication at school readiness
               programs and before-and-after school programs shall be reviewed
               annually by the school medical advisor, if any, and school nurse
               supervisor.

M.     Review and Revision of Policy

        In accordance with the provisions of Conn. Gen. Stat. Section 10-212a(a)(2), the
Board shall review this policy periodically, and at least biennially, with the advice and
approval of the school medical advisor, if any, or other qualified licensed physician, and
the school nurse supervisor. Any proposed revisions to the policy must be made with
the advice and approval of the school medical advisor, school nurse supervisor or other
qualified licensed physician.
Legal References: Connecticut


General Statutes:


     Section 10-206
     Section 10-212
     Section 10-212a
     Section 10-220j
     Section 19a-900
     Section 21a-240
     Section 52-557b




                         ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 31 of 33
Public Act 18-185, “An Act Concerning the Recommendations of the Task Force on Life-
Threatening Food Allergies in Schools”

Regulations of Conn. State Agencies:
    Sections 10-212a-1 through 10-212a-10, inclusive

Memorandum of Decision, In Re: Declaratory Ruling/Delegation by Licensed Nurses to
       Unlicensed Assistive Personnel, Connecticut State Board of Examiners for
       Nursing (April 5, 1995)

ADOPTED: August 26, 2015
REVISED: November 13, 2018

238944v32




                        ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS         Page 32 of 33
                        Colchester Public Schools
                        127 Norwich Avenue, Suite 202
                        Colchester, CT 06415



Jeffrey E. Burt                                                     Phone (860) 537-7208
Superintendent of Schools                                           jburt@colchesterct.org

      REFUSAL TO PERMIT ADMINISTRATION OF EPINEPHRINE FOR EMERGENCY FIRST AID

Name of Child:                              Date of Birth:

Address of Child:

Name of Parent(s):

Address of Parent(s):
(if different from child)

Connecticut law requires the school nurse and other qualified school personnel in all public
schools to maintain epinephrine in cartridge injectors (EpiPens) for the purpose of
administering emergency first aid to students who experience allergic reactions and do not
have a prior written authorization of a parent or guardian or a prior written order of a qualified
medical professional for the administration of epinephrine. State law permits the parent or
guardian of a student to submit a written directive to the school nurse or school medical
advisor that epinephrine shall not be administered to such student in emergency situations.
This form is provided for those parents who refuse to have epinephrine administered to their
child. The refusal is valid for only for the 2018-2019 school year.



I,                                         , the parent/guardian of                         ,
refuse to permit the administration of epinephrine to the above named student for purposes of
emergency first aid in the case of an allergic reaction.


Signature of Parent/Guardian                                        Date

Please return the completed original form to your child’s school nurse.
11/2018




                             ADMINISTRATION OF STUDENT MEDICATIONS IN THE SCHOOLS            Page 33 of 33