Health Services

Medication Details

A Medication Permission Form needs to be completed by a parent/guardian and physician if it will be necessary for any medication (prescription or over-the-counter including Benadryl, Tylenol, Ibuprofen or cough drops) to be received by the student at school. The Catholic Diocese medication policy states, the school will not administer aspirin to students because of its connection to Reye's Syndrome.î Forms must have an original physician's signature. No stamps or faxes will be accepted. The form must be completed thoroughly and accurately. This includes medication, exact dosage, route, when to administer (please see form)

Medication must be kept in a prescription labeled bottle that exactly matches the directions on the medication form. (Pharmacy may provide and extra bottle for long-term mediation.) The prescriber of the medication must be the one who completes the medication form. If it is a non-prescription drug, it must be in the original container with your child's name on it.

A revised statement signed by the physician must be provided for any changes in the dosage to be given.

When possible, give medication doses around school hours (for example: before school, immediately after school, before child's bedtime, and before parents' bedtime-to get in four doses). For further help in adjusting dosage time, please consult your physician.

Transporting Medications

Medications cannot be transported on a daily basis. If your child needs medicine at school, please send a separate supply of the medication for the duration of administration must be sent to the clinic.

Inhaler and Epinephrine Laws

The law allows students to carry their own inhalers and Epinephrine auto-injectors, provided, the proper paperwork has been completed by both the parent and physician. Please call the nurse to request the forms and discuss the plans specific to your child. It is recommended that an inhaler also be kept in the clinic and an additional Epinephrine auto-injector is required to be kept in the clinic.

Request to Administer Medication Form

Please note, each medication requires its own form to be completed by a parent/guardian and physician.

1. Medication Information for Anyone -- updated 5/15
2. Request To Administer Medication to a Student During School Hours Form -- updated 8/14

Allergy Forms

If your child requires medication at school for an allergy, please have an Allergy Action Plan form as well as a Request to Administer Medication to a Student During School Hours form filled out by the parent/guardian and physician.  Each medication requires its own Request to Administer Medication to a Student During School Hours form.  For self-carry Epinephrine Autoinjector permission, both the Request to Administer Medication to a Student During School Hours and Authorization for Student Possession and Use of an Epinephrine and Autoinjector forms need to be completed by the physician and the parent/guardian.

Print out and complete the following:
1. Medication Information for Anyone -- updated 5/15
2. Request to Administer Medication to a Student During School Hours Form (one form per medication) -- 8/14
3. Allergy Action Plan Form -- updated 5/17
4. Self carry Epinephrine Autoinjector Permission Instructions -- updated 8/14
5. Authorization for Possession and Use of an Epinephrine Autoinjector Form -- updated 8/14

Asthma Forms

Any student who has asthma must have a Student Asthma Information form completed by a parent or guardian. If the student needs medication anytime during school hours, a Request to Administer Medication to a Student During School Hours form must be completed by a parent/guardian and physician. For self-carry permission both the Request to Administer Medication to a Student During School Hours and Authorization for Student Possession and Use of an Asthma Inhaler forms need to be completed by both the physician and parent in order to have self-carry permission.

Print out and complete the following:
1. Medication Information -- updated 8/14
2. Request to Administer Medication to a Student During School Hours Form (one form per medication) -- 8/14
3. Student Asthma Information Form -- updated 8/14
4. Self-Carry Asthma Permission Instructions -- updated 8/14
5. Authorization for Possession and Use of an Asthma Inhaler Form -- updated 8/14

Kindergarten and New Student Forms

1. Health History Questionnaire Form (3 pages)
2. Immunization Summary - Parent/Guardian must submit student's immunization record from his/her physician.
3. Ohio School Health Record Physician's Report Form (2 pages)

Referral Forms

1. Hearing Screening Report Form
2. Vision Screening Referral Report  (2 pages)
3. Immunization Clinic Hours and Fee Schedule (Part 1 of 2)
4. Immunization Clinic Hours and Fee Schedule (Part 2 of 2)