Submit the completed form to the school nurse or School Based Health Center (SBHC) before June 1, 2024, to ensure timely processing for the new school year. Forms can be submitted via email, fax, or in person. Verify submission details with your school for specific instructions. It's important to ensure the form is complete and signed by both the health care practitioner and the parent/guardian to avoid any delays.

Submit the form before June 1, 2024, to avoid delays in processing for the 2024-2025 school year.

The Asthma Medication Administration Form is designed to ensure that students with asthma receive proper medication management during school hours. It provides a standardized way for health care practitioners to outline the asthma treatment plan and for parents/guardians to give consent for medication administration. Proper completion and submission of this form help maintain the student's health and safety in the school environment.

• 1. Student Personal Information: Includes fields for the student's last name, first name, middle initial, date of birth, sex, OSIS number, DOE district, grade/class, and school details.
• 2. Diagnosis and Medication Order: Sections for the health care practitioner to provide the student's asthma diagnosis, control, severity, and medication orders.
• 3. Student Asthma Risk Assessment Questionnaire: Questions to assess the student's asthma risk, answered with Yes, No, or Unknown.
• 4. Home Medications: Fields to list reliever, controller, and other medications the student takes at home.
• 5. Student Skill Level: Options to indicate whether the student is nurse-dependent, supervised, or independent in administering medication.
• 6. Quick Relief In-School Medication: Instructions for administering quick relief medications during school hours, including albuterol dosages.
• 7. Controller Medications for In-School Administration: Details for administering controller medications during school hours, including dosage and timing.
• 8. Health Care Practitioner Information: Fields for the health care practitioner's name, credentials, license number, NPI number, signature, date, and contact details.
• 9. Parent/Guardian Consent and Information: Sections for parents/guardians to consent to medication administration, provide contact information, and sign the form.
• 10. Office of School Health Use Only: Fields for OSH staff to document receipt of the form, review details, and provide additional services if needed.
• 11. Emergency Contact Information: Fields for listing additional emergency contacts along with their relationship and phone numbers.

Failing to submit this form may result in the student not receiving proper asthma care during school hours.

• Health Risks: The student may face health risks without proper medication administration.
• Delayed Treatment: Delays in treatment can occur if the form is not submitted on time.
• Lack of Consent: Without parental consent, the school cannot administer necessary medications.

• 1. New School Year: Submit the form at the beginning of the school year for asthma management.
• 2. Change in Medication: Provide updated information if there are changes in the student's medication.
• 3. Field Trips: Ensure the form is up to date for school-sponsored field trips.
• 4. Medical Emergencies: Have the form on file for any asthma-related emergencies at school.
• 5. Annual Updates: Submit a new form annually to keep the student's medical records current.