MANDATED MEDICATION LOG School Year 2011-2012

Joliet Public School District 86Special Services Department420 North Raynor Avenue, Joliet, IL 60435MANDATED MEDICATION LOG School Year 2011-2012 815/740-3196- Fax 815/740-5955Students Name:______________________________Medication: ______________________________________School:___________________ Grade:___________ Dose:_________________________ Time:___________Teacher: RX: Monitored By:Codes: A: ABSENT X: NO SCHOOL F: FIELD TRIP W: DOSE WITHHELD H: HOLDIAYN: NONE AVAILABLE E: EARLY DISMISSAL O: NO SHOW T: TRANSFERAUGUST 2011Monday Tuesday Wednesday Thursday Friday1 2 3 4 58 9 10 11 1215 16 17 18 1922 23 24 25 2529 30 31JANUARY 2012Monday Tuesday Wednesday Thursday Friday2 3 4 5 69 10 11 12 1316 17 18 19 2023 24 25 26 2730 31SEPTEMBER 2011Monday Tuesday Wednesday Thursday Friday1 25 6 7 8 912 13 14 15 1619 20 21 22 2326 27 28 29 30OCTOBER 2011Monday Tuesday Wednesday Thursday Friday3 4 5 6 710 11 12 13 1417 18 19 20 2124 25 26 27 2831NOVEMBER 2011Monday Tuesday Wednesday Thursday Friday1 2 3 47 8 9 10 1114 15 16 17 1821 22 23 24 2528 29 30DECEMBER 2011Monday Tuesday Wednesday Thursday Friday1 25 6 7 8 912 13 14 15 1619 20 21 22 2326 27 28 29 30Comments: Initial & Date Each entry_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________INITIAL PRINTED NAME INITIAL PRINT NAME____________ __________________ ________ __________________________ __________________ ________ __________________________ __________________ ________ ______________FEBRUARY 2012Monday Tuesday Wednesday Thursday Friday1 2 36 7 8 9 1013 14 15 16 1720 21 22 23 2427 28 29MARCH 2012Monday Tuesday Wednesday Thursday Friday1 25 6 7 8 912 13 14 15 1619 20 21 22 2326 27 28 29 30APRIL 2012Monday Tuesday Wednesday Thursday Friday2 3 4 5 69 10 11 12 1316 17 18 19 2023 24 25 26 2730MAY 2012Monday Tuesday Wednesday Thursday Friday1 2 3 47 8 9 10 1114 15 16 17 1821 22 23 24 2528 29 30 31JUNE 2012Monday Tuesday Wednesday Thursday Friday14 5 6 7 811 12 13 14 1518 19 20 21 2225 26 27 28 29JULY 2012Monday Tuesday Wednesday Thursday Friday2 3 4 5 69 10 11 12 1316 17 18 19 2023 24 25 26 2730 31

Dear Parent or Guardian:MEDICATION SELF ADMINISTRATION CONSENT 2011-2012Because of liability factors involved with dispensing of any type of medication and district policy, WE ARE UNABLE TO COMPLY WITH ANY REQUESTS TOADMINISTER MEDICATION UNLESS PROPER FORM (see below) HAS BEEN COMPLETED BY BOTH PARENT AND THE PHYSICIAN.We are sure you understand how important this should be handled in a consistent, structured manner. Upon receipt of the completed form, we will follow the indicatedprocedures in administering medication to your child.Thank you for your cooperation.DISTRICT #86 MEDICATION POLICY_________________________________________Sandra L. Thomas, Ed. D.Director of Special ServicesWhen a child requires medication, the primary responsibility for administering such medication rests solely upon the parents. The district recognizes that some shortand long term conditions can be controlled or corrected only when medicated at intervals, which may include school hours. In those instances, when the doctor hasdetermined that administration during school hours is necessary for optimum benefits, the school district endorses the following procedure:1. Medications are defined as over-the-counter and registered prescription drugs.2. The physician will complete the ORDER FOR MEDICATION.3. The parent will complete the PARENT’S REQUEST TO ADMINISTER MEDICATION4. Medication will be in the original container or prescription bottle appropriately labeled by the pharmacys, physician or manufacturer.5. Medication will be stored in school in a locked cabinet.6. For students participating in field trips and after school activities, their medication will be monitored by adult supervisors.PARENT PLEASE FILL THIS TOP SECTION:month day yearStudents Name:_________________________ Date of Birth:_______/_______/_________School Name: _____________________ Grade:__________ School Year: 2011-2012PARENT’S PLEASE FILL CONSENT FOR STUDENT TO ADMINISTER MEDICATION AT SCHOOL.I hereby request that Joliet Public School District 86 allow my child_______________________________ at ______________________Schoolto self-administer the medication listed on the bottom of the page ordered byDOCTOR:________________________________Medication Name:__________________________Time:___________________________Prescription #:_______________________________________________Pharmacy Name:_____________________________________________Address:_____________________________________________Phone:_____________________________________________I can be reached at the following telephone number(s) in case there is a problem or question( )__________________ ( )_______________________ ( )_______________________I understand that my child is responsible for the administration for this medication.Parent/Guardian Signature_________________________________________ Today’s Date:____________________________________________________________________________________________________________________________________________________________PHYSICIAN PLEASE FILL THIS BOTTOM SECTION: SCHOOL YEAR 2011-2012PHYSICIAN’S ORDER FOR MEDICATION AT SCHOOL.I have determined that the following medication must be taken during school hours.MEDICATION:______________________________________________________________DOSE & FREQUENCY:_______________________________________________________Purpose of Medicine:__________________________________________________________Side Effects:_________________________________________________________________Date of Order:__________________Re-eval Date:__________________Discontinue Date:____________________Route of Administration:PO INHALE INJECTIONOther __________________________Other medications child is taking: _______________________________________________________________________________________Doctors Signature:_________________________________________Today’s Date: _________________________________________Doctors printed name:________________________________________ Doctos Phone: ( ) :____________________________Doctor’s Address:____________________________________________Medication must bebrought to school byparent. Do not sendmedication withstudent on bus.1.The buildingprincipal will beresponsible foradministration ofmedication an theaccuracy of theMANDATEDMEDICATION LOG.2. The school nursewill monitor themedication procedure.Upon completion ofmedication and/or endof school year, theschool nurse will beresponsible for filing themandated medicationform in the child’shealth record.3. When a childtransfers out themandated medicationlog will be filed inchild’s health record. Acopy of the doctor’smedication order/parentrequest form should begiven to the parent. Theparent will be given theremaining medication.4. At the end of theschool year, allremaining medicationwill be returned toparent in person ordestroyed by thecertified school nurse inthe presence of awitness.Review & Approved by School Nurse:Date: