Spearfish School District 40-2
5000 Students

5310.2FM

PHYSICIAN’S CONSENT/ORDER FORM

I authorize the Principal/designee of __________________________ School

to administer _____________________________________________________
(Medication Name/Prescription Number)

to ________________________________ in grade _______________________
(Name)

at the times indicated below (check times):

1. _____ Medication at _________o’clock and at __________ o’clock.

2. _____ As necessary to control asthma or wheezing for which this medication was especially prescribed. Repeat doses of medication should not be more often than every _______ hours.

3. Other directions or instructions to be observed:
_______________________________________________________________

This authorization will terminate completely on ________________________.
(Specific Date)

(Date of Authorization) (Signature of Physician)

FM5310

5310.3FM

INCIDENT REPORT - MEDICATION ADMINISTRATION

Name of School:______ _______________________________________________

Name of Student:______ ______________________________________________

Birth Date:__________________ (month/day/year)

Date and time of error:_______ ________________________________________

Name of person administering medication:_______ ________________________

Name of medication and dosage prescribed:_______ _______________________

Describe circumstances leading to error:______ __________________________
______ _____________________________________________________________
______ _____________________________________________________________

Describe action taken:_______________________________________________
_____ ______________________________________________________________

Persons notified of error:

Supervisor______ ______________________________________________
Principal _______ ______________________________________________
Parent(s) _______ ______________________________________________
Physician (if applicable)_____ ____________________________________
Other _____ ___________________________________________________

Person completing incident report

___________________________________________/____________________________
(Signature) (Date)

Follow-up information, if applicable______ ______________________________
_____ ______________________________________________________________
_____ ______________________________________________________________
_____ ______________________________________________________________

FM5310