The Maine Department of Education offers this sample medication authorization for school nurses to adapt with their own school logo. When a student needs medication during school hours, the parent requests it and the prescriber completes a statement that the medication is required at school to improve or maintain the student's health, with the full order.
The parent completes the student details and signs the parent statement. The prescriber completes the Healthcare Provider Statement and signs it, and the school nurse signs the bottom of the form.
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Medication Authorization (Sample)
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It is a sample. The Maine Department of Education provides it as a template marked for the school to insert its own logo or school administrative unit name, so a district may use its own version with the same content.
Yes. The Department of Education posts translated versions for families, including Arabic, Chinese, French, Portuguese, Somali, Spanish, Vietnamese, Kinyarwanda and Lingala, alongside the English template. They sit with the other sample family forms, such as the annual health form and the asthma, seizure and diabetes interviews.
Yes. The provider statement says the nurse may contact the prescriber about the medication, and the parent statement says the school nurse may contact the health care provider or pharmacist regarding the treatment.