Student's Name (Last), (First) (Middle)                                                                                                                      Birthday ___/___/___

School                                                                                                                                                                        Date ___/___/___

  

The following must occur for a student to self-administer asthma or other airway constricting disease medication or for a student with a risk of anaphylaxis to self-administer an epinephrine auto-injector:

• Parent/guardian provides signed, dated authorization for student medication self-administration.
• Parent/guardian provides a written statement from the student's licensed health care professional (A person licensed under chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under chapter 152 or 152E and registered with the board of nursing, or a physician assistant licensed to practice under the supervision of a physician as authorized in chapters 147 and 148C) containing the following:
  • Name and purpose of the medication,
  • Prescribed dosage, and
  • Times or special circumstances under which the medication or epinephrine auto-injector is to be administered.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.
• Authorization shall be renewed annually. In addition, if any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.

Provided the above requirements are fulfilled, the school shall permit the self-administration of medication by a student with asthma or other airway constricting disease or the use of an epinephrine auto-injector by a student with a risk of anaphylaxis while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before-school or after-school care on school-operated property. If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student's parent.

Pursuant to state law, the school district or and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine auto-injector by the student as provided by law.

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AUTHORIZATION ASTHMA OR OTHER AIRWAY CONSTRICTING MEDICATION

SELF-ADMINISTRATION CONSENT FORM

             

Medication                                                                                      Dosage                                 Route                                 Time                               

Purpose of Medication & Administration Instructions                                                                                                                                                    

                                                                                                                                                                                                                                       

Special Circumstances                                                                                                                                                                                                   

                                                                                                                                                                                                                                       

                                    /                       /                       

            Discontinue / Re-Evaluate / Follow-up Date

   

Prescriber's Signature                                                                                        Date ___/___/___

  

• I request the above named student possess and self-administer asthma or other airway constricting disease medication(s) and/or an epinephrine auto-injector at school and in school activities according to the authorization and instructions.
• I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or an epinephrine auto-injector or for supervising, monitoring, or interfering with a student's self-administration of medication or use of an epinephrine auto-injector. I acknowledge that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or use of an epinephrine auto-injector by the student.
• I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.
• I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.
• I agree the information is shared with school personnel in accordance with the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.
• I agree to provide the school with back-up medication approved in this form.
• (Student maintains self-administration record.) (Note: This bullet is recommended but not required.)

  

Parent/Guardian Signature                                                                                       Date ___/___/___(agreed to above statement)

Parent/Guardian Address                                                                                                                                                              

Business Phone                                                                       Home Phone                                                                                 

   

Self-Administration Authorization Additional Information

 

Student's Name (Last), (First) (Middle)                                                                                                                      Birthday ___/___/___

School                                                                                                                                                                        Date ___/___/___

    

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer medication and/or provide the health service.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container.
• The medication label contains the student's name, name of the medication, directions for use, and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

  

Medication / Healthcare                                                                                      Dosage                             Route                            Time at School                           

Administration instructions:

 Special Directives, Signs to Observe and Side Effects:

                                                                                                                                                                                     

                                    /                       /                       

            Discontinue / Re-Evaluate / Follow-up Date

   

Prescriber's Signature                                                                                        Date ___/___/___

Prescriber's Address                                                                                                         Emergency Phone                                               

I request the above named student carry medication at school and school activities, according to the prescription, or other medication administration instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided by the Family Educational Rights and Privacy Act (FERPA) and any other applicable law. I agree to coordinate and work with school personnel and prescriber (if any) when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment. Procedures for medication disposal shall be in accordance with federal and state law.

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PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION

OF MEDICATION TO STUDENTS

Parent/Guardian Signature                                                                                        Date ___/___/___

Parent/Guardian Address                                                                                                                 Business Phone                                 Home Phone                               

   

Additional Information                                                                                                                                                  

Authorization Form

                                                                                                                                                                     

Some students who require special education need special health services in order to participate in the educational program. These students will receive special health services in accordance with their individualized educational program.

A. Definitions

"Assignment and delegation" - occurs when licensed health personnel, in collaboration with the education team, determine the special health services to be provided and the qualifications of individuals performing the health services. Primary consideration is given to the recommendation of the licensed health personnel. Each designation considers the student's special health service. The rationale for the designation is documented. If the designation decision of the team differs from the licensed health professional, team members may file a dissenting opinion.

"Co-administration" - the eligible student's participation in the planning, management and implementation of the student's special health service and demonstration of proficiency to licensed health personnel.

"Educational program" - includes all school curricular programs and activities both on and off school grounds.

"Education team" - may include the eligible student, the student's parent, administrator, teacher, licensed health personnel, and others involved in the student's educational program.

"Health assessment" - health data collection, observation, analysis, and interpretation relating to the eligible student's educational program.

"Health instruction" - education by licensed health personnel to prepare qualified designated personnel to deliver and perform special health services contained in the eligible student's health plan. Documentation of education and periodic updates are on file at school.

"Individual health plan" - the confidential, written, preplanned and ongoing special health service in the educational program. It includes assessment, planning, implementation, documentation, evaluation and a plan for emergencies. The plan is updated as needed and at least annually. Licensed health personnel develop this written plan with the education team.

"Licensed health personnel" - includes licensed registered nurse, licensed physician, and other licensed health personnel legally authorized to provide special health services and medications.

"Prescriber" - licensed health personnel legally authorized to prescribe special health services and medications.

"Qualified designated personnel" - persons instructed, supervised and competent in implementing the eligible student's health plan.

"Special health services" - includes, but is not limited to, services for eligible students whose health status (stable or unstable) requires:

• Interpretation or intervention,
• Administration of health procedures and health care, or
• Use of a health device to compensate for the reduction or loss of a body function.

"Supervision" - the assessment, delegation, evaluation and documentation of special health services by licensed health personnel. Levels of supervision include situations in which licensed health personnel are:

• physically present.
• available at the same site.
• available on call.

B. Licensed health personnel will provide special health services under the auspices of the school. Duties of the licensed personnel include the duty to:

• Participate as a member of the education team.
• Provide the health assessment.
• Plan, implement and evaluate the written individual health plan.
• Plan, implement and evaluate special emergency health services.
• Serve as liaison and encourage participation and communication with health service agencies and individuals providing health care.
• Provide health consultation, counseling and instruction with the eligible student, the student's parent and the staff in cooperation and conjunction with the prescriber.
• Maintain a record of special health services. The documentation includes the eligible student's name, special health service, prescriber or person authorizing, date and time, signature and title of the person providing the special health service and any unusual circumstances in the provision of such services.
• Report unusual circumstances to the parent, school administration, and prescriber.
• Assign and delegate to, instruct, provide technical assistance and supervise qualified designated personnel.
• Update knowledge and skills to meet special health service needs.

C. Prior to the provision of special health services the following will be on file:

• Written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated.
• Written statement by the student's parent requesting the provision of the special health service.
• Written report of the preplanning staffing or meeting of the education team.
• Written individual health plan available in the health record and integrated into the IEP or IFSP.

D. Licensed health personnel, in collaboration with the education team, will determine the special health services to be provided and the qualifications of individuals performing the special health services. The documented rationale will include the following:

• Analysis and interpretation of the special health service needs, health status stability, complexity of the service, predictability of the service outcome and risk of improperly performed service.
• Determination that the special health service, task, procedure or function is part of the person's job description.
• Determination of the assignment and delegation based on the student's needs.
• Review of the designated person's competency.
• Determination of initial and ongoing level of supervision required to ensure quality services.

E. Licensed health personnel will supervise the special health services, define the level of supervision and document the supervision.

F. Licensed health personnel will instruct qualified designated personnel to deliver and perform special health services contained in the eligible individual health plan. Documentation of instruction and periodic updates are on file at school.

G. Parents will provide the usual equipment, supplies and necessary maintenance for such. The equipment is stored in a secure area. The personnel responsible for the equipment are designated in the individual health plan. The individual health plan will designate the role of the school, parents, and others in the provision, supply, storage and maintenance of necessary equipment.

 

To implement the Wellness Policy, the following district specific goals have been established:

Goal 1 - Nutrition Education and Promotion: Schools will provide nutrition education and engage in nutrition promotion that help students develop lifelong healthy eating behaviors. The goal(s) for addressing nutrition education and nutrition promotion include the following:

• Provide students with the knowledge and skills necessary to promote and protect their health;
• Ensure nutrition education and promotion are not only part of health education classes, but also integrated into other classroom instruction through subjects such as math, science, language arts, social sciences, and elective subjects;
• Include enjoyable, developmentally-appropriate, culturally-relevant, and participatory activities, such as cooking demonstrations or lessons, promotions, taste-testing, farm visits, and school gardens;
• Promote fruits, vegetables, whole-grain products, low-fat and fat-free dairy products, and healthy foods;
• Emphasize caloric balance between food intake and energy expenditure (promotes physical activity/exercise);
• Link with school meal programs, cafeteria nutrition promotion activities, school gardens, Farm to School programs, other school foods, and nutrition-related community services;
• Implement evidence-based healthy food promotion techniques through the school meal programs using Smarter Lunchroom techniques;
• Teach media literacy with an emphasis on food and beverage marketing;
• Include nutrition education training for teachers and other staff; and/or

 

Goal 2 - Physical Activity: Schools will provide students and staff with age and grade appropriate opportunities to engage in physical activity that meet federal and state guidelines, including the Iowa Healthy Kids Act. The goal(s) for addressing physical activity include the following:

• Develop a comprehensive, school-based physical activity program (CSPAP), that includes the following components:
  • Physical education, recess;
  • Classroom-based physical activity;
  • Walk to school; and
  • Out of school time activities;
• Promote the benefits of a physically active lifestyle and help students develop skills to engage in lifelong healthy habits;
• Engage students in moderate to vigorous activity during at least 50 percent of physical education class time;
• Encourage classroom teachers to provide short physical activity breaks (3-5 minutes), as appropriate;
• Encourage teachers to incorporate movement and kinesthetic learning approaches into core subject instructions when possible;
• Offer classroom health education that complements physical education by reinforcing the knowledge and self-management skills needed to maintain a physically active lifestyle;
• Ensure physical activity is not used for or withheld as a punishment;
• Afford elementary students with recess according to the following:
  • At least 20 minutes a day;
  • Outdoors as weather and time permits;
  • Encourages moderate to vigorous physical activity; and
• Scheduled to avoid extended periods of inactivity (i.e., periods of two or more hours). and/or

Goal 3 - Other School-Based Activities that Promote Student Wellness: Schools will support student, staff, and parents' efforts to maintain a healthy lifestyle, as appropriate. The goal(s) for addressing other school-based activities that promote student wellness include the following Select goal(s) from the list below:

• Provide parents a list of foods and beverages that meet nutrition standards for classroom snacks and celebrations;
• Provide school staff a list of alternative ways to reward children. Foods and beverages will not be used as a reward, or withheld as punishment;
• Develop a plan to promote staff health and wellness;
• Engage students and parents, through taste-tests of new school meal items and surveys to identify new, healthful, and appealing food choices;
• Share information about the nutritional content of meals with parents and students;
• Support the consumption of breakfast at school by implementing alternative breakfast options to the extent possible (e.g., grab n' go, breakfast in the classroom, breakfast after 1st period, etc.);
• Permit students to bring and carry water bottles filled with water throughout the day;
• Make drinking water available where school meals are served during mealtimes;
• Encourage fundraising efforts held outside school hours to sell only non-food items, promote physical activity, or include foods and beverages that meet or exceed the Smart Snacks nutrition standards;
• Strive to provide students with at least 10 minutes to eat after sitting down for breakfast and 20 minutes after sitting down for lunch;
• Discourage students from sharing foods or beverages during meal or snack times, given concerns about allergies and dietary needs;

Public Involvement: There is a process for permitting parents, students, representatives of the school food authority, teachers of physical education, school health professionals, the school board, administrators and the public to participate in the development, implementation, and periodic review and update of the policy select a process from the list below.

• The district has a local wellness policy committee to advise the district on the development, implementation, and improvement of the school wellness policy