507.2E1 Authorization Asthma or Airway Constricting Medicadtion Self-Administration Consent Form

 

Student's Name (Last), (First)(Middle) ______________________________________________ 

Birthday ___/___/___

School                                                                                                                                                 Date ___/___/___

   

In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency.  The following must occur for a student to self-administer asthma medication, bronchodilator canisters or spacers, or other airway constricting disease medication or 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 prescribed medication 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 the prescribed medication by a student 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 medication, bronchodilators canisters or spacers, 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.

   

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 special health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide the special health services listed.  Electronic signature meet the requirement of written signatures..
• The prescribed medication is in the original, labeled container.
• The prescription medication label contains the student's name, name of the medication, the medication dosage, time(s) to administer, route to administer, and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

   

Prescribed Medication                                                                                      Dosage                             Route                             Time at School                            

 

Special Health Services and instructions, in indicated: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

                               /                      /                        

    Discontinue / Re-Evaluate / Follow-up Date for Prescribed Medication or Special Health Services listed

    

Prescriber's Signature                                                                                        Date ___/___/___

Add credentials (when indicated for health service delivery

 

Parent/Guardian Signature and Date:

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PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION OR SPECIAL HEALTH SERVICES TO STUDENTS

Parent/Guardian Signature                                                                                   Date ___/___/___

 

Parent/Guardian Address                                                                                                    

Business Phone                                 Home Phone                                

    

Additional Information

Some students require special education needs special health services in order to participate in educational program. The students shall 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, in accordance with licensed practivcefor the designation is documented. If the designation decision of the

team differs from a licensed health professional, team members may file a dissenting opinion in the student's educational record.

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 parents,

administrator, teacher, licensed health personnel, and others involved in the student's educational program, or as described in the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act of 1973..

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 in periodic update shall be on file at school.

Individual Health Plan - the confidential, written, preplanned, and ongoing special health service in the educational program. It includes assessment, nursing diagnosis, outcomes, planning, interventions, evaluation, student goals, if applicable, and a plan for emergencies. The plan is updated as needed and at least annually. Licensed health personnel develop this written plan with collaboration from the parent or guardian, individual's health care provider or 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 under the auspices of the school.

Prescriber - licensed health personnel legally authorized to prescribe special health service and medication.

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 shall 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 a liaison to encourage participation in communication with health service agencies and individuals providing health care.
• Provide health consultation, counseling and instruction with the eligible student, the student's parents and the staffing cooperation in 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, in any unusual circumstances in the provision of such services.
• Report unusual circumstance 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.

 

The school district will provide nutrition education and engage in nutrition promotion that:

• is offered at each grade level as part of a sequential, comprehensive, standards-based program designed to provide students with the knowledge and skills necessary to promote and protect their health;
• is part of not only health education classes, but also classroom instruction in subjects not directly related to health and elective subjects whenever possible.;
• includes enjoyable, developmentally appropriate, culturally relevant participatory activities such as promotion and taste testing;
• promotes fruits, vegetables, whole-grain products, low-fat and fat-free dairy products, healthy food preparation methods and health-enhancing nutrition practices;
• emphasizes caloric balance between food intake and physical activity;

Physical Education

The school district will provide physical education that:

• is for all students in grades K-12 for the entire school year;
• is taught by a certified physical education teacher;
• includes students with disabilities, students with special health-care needs may be provided in alternative educational settings; and,
• Students in grades K-5 will be provided at least 30 minutes of physical activity each day.
• Students in grades 6-12 will be provided at least 120 minutes of physical activity each week.

Physical Activity and Punishment

Employees are discouraged from using physical activity (e.g., running laps, pushups) or withhold opportunities for physical activity (e.g., physical education) as punishment. When activities, such as mandatory school-wide testing make it necessary for students to remain indoors for long periods of time, school should give students periodic breaks during which they are encouraged to stand and be moderately active.

Integrating Physical Activity into Classroom Settings

The Wapello Community School System recognizes that in order for students to receive the nationally recommended amount of physical activity and for students to fully embrace regular physical activity as a personal behavior, ALL students need opportunities for physical activity beyond the physical education class. Toward this end, Wapello Community School District will:

• offer classroom health education that complements physical education by reinforcing the knowledge and self-management skills needed to maintain a physically active lifestyle and to reduce time spent on sedentary activities;
• discourage sedentary activities, such as watching television, playing computer games, etc.;
• provide opportunities for physical activity to be incorporated into other subject lessons; and,
• encourage classroom teachers to provide short physical activity breaks between lessons or classes, as appropriate.

Communication with Parents

The Wapello Community School District will support parents’ efforts to provide a healthy diet and daily physical activity for their children. The school district will:

• encourage parents to pack healthy lunches and snacks, including beverages that meet the school's nutrition standards;
• support parents' efforts to provide their children with opportunities to be physically active outside of schoo

Food Marketing in Schools

Wapello school-based marketing will be consistent with a focus on health promotion and should:

• limit foods that do not meet school nutrition standards when sold individually;
• promote healthy foods, including fruits, vegetables, whole grains, and low-fat dairy products; and
• promote juices, water, and dairy products market activities that promote healthful behaviors including: pricing structures that promote healthy options in ala carte lines, including vending machines.
• Market activities that promote healthful behaviors

Staff Wellness

The school district values the health and well-being of every staff member. To this end:

• The district should designate the school nurse as the wellness coordinator and establish a staff wellness committee that will develop a plan that will demonstrate and challenge staff to healthy eating, physical activity, and healthy lifestyles.:
• The committee shall yearly have a multi-faceted plan to entice staff to support one another in becoming healthy individuals.

School Meals

Meals served through the National School Lunch and Breakfast Programs will:

• be appealing and attractive to children;
• be served in clean and pleasant settings;
• meet, at a minimum, nutrition requirements established by local, state and federal law:
• Offer low-fat (1 %) and fat-free milk and nutritionally equivalent non-dairy alternatives
• Encourage the consumption of whole grain.
• Share information about nutritional contect of meals with parents and students

Breakfast

To ensure that all children have breakfast, either at home or at school, in order to meet their nutritional needs and enhance their ability to learn, schools will:

• operate the breakfast program, to the extent possible;
• notify parents and students of the availability of the School Breakfast Program, through the use of the website, newsletter, etc...; and,
• encourage parents to provide a healthy breakfast for their children if the parents choose not to use the School Breakfast Program. This can be done through newsletter articles, take-home materials or other means.

Meal Times and Scheduling

The school district:

• will provide students with at least 10 minutes to eat after sitting down for breakfast and 20 minutes after sitting down for lunch. When occasions arise in which the students do not get this amount of time, procedures should be in place to allow longer eating times;
• should schedule meal periods at appropriate times, e.g., lunch should be scheduled between 11 a.m. and 1 p.m.;
• should not schedule tutoring, club or organizational meetings or activities during mealtimes, unless students may eat during such activities;
• will provide students access to hand washing or hand sanitizing before they eat meals or snacks; and,
• Have accessible drinking water available during school meals;
• should take reasonable steps to accommodate the tooth-brushing regimens of students with special oral health needs (e.g., orthodontia or high tooth decay risk).

Qualification of Food Service Staff

Qualified nutrition professionals will administer the meal programs. As part of the school district’s responsibility to operate a food service program, the school district will:

• provide continuing professional development for all nutrition professionals; and,
• provide staff development programs for cafeteria workers and nutrition managers according to their level of responsibility.
• In school year 2015-2016, the first year of implementation, program directors must complete 8 hours of training; program managers, 6 hours of training ; and program staff, 4 hours of training.

Sharing of Foods

The school district discourages students from sharing their foods or beverages with one another during meal or snack times, given concerns about allergies and other restrictions on some children’s diets.

Beverages

• Encouraged:Water, seltzer, water without added caloric sweeteners, fruit and vegetable juices, fruit-based drinks containing 100% fruit juice, unflavored or flavored low-fat or fat-free milk..
•  Discouraged: All soft drinks, sports drinks, beverages with caffeine excluding low-fat or fat-free chocolate milk

Foods

A food item sold individually should have:

• Less than 10% of calories from saturday fat and zero grams of trans fat
• No more than 35% of weight from added sugars
• No more than 200mg of sodium per serving for chips, cereals, crackers, and other snack items
• No more than 480mg of sodium per serving for pizza, sandwiches, and main dishes.
• The inclusion of at least one fruit or non-fried vegetable at any location on a school site where foods are sold.  Grain products must include 50% or more whole grain by weight or have whole grain as the 1st ingredient.

Portion Size

The Wapello School District will strive to limit serving sizes to these recommended standards:

• One and one-quarter ounces of chips, crackers, popcorn, cereal, trail mix, nuts, seeds, dried fruits, or jerky
• One ounce for cookies.
• Two ounces for cereal bars, granola bars, pastries, muffins, doughnuts, bagels, and other bakery items
• Eight ounces for non-frozen yogurt
• Twelve fluid ounces for beverages, excluding water and milk

 

Food Safety

All foods made available on campus adhere to food safety and security guidelines.

All foods made available on campus comply with the state and local food safety and sanitation regulations. Hazard Analysis and Critical Control Points (HACCP) plans and guidelines are implemented to prevent food illness in schools.

 

Wellness Committee

The Wellness Committee shall be appointed each year. Membership will include: building principal, food service representative, PE instructor from each building, health instructor, school nurse, board member, persons that would give representation of parents.

In each school:

• the committee will monitor the district-wide nutrition and physical activity wellness policies. The following will have specific responsibilities: Food service staff at the school district level will ensure compliance with nutrition policies within food service areas and will report this matter to the district wellness committee; they shall yearly plan their emphasis in the nutrition program.
• The school nurse will monitor the staff wellness efforts and report yearly to the district wellness committee.

• the PE and Health instructors will indicate their emphasis for the year and report results to the Wellness committee;
• the building principals shall report on selections in the vending machines as in reference to the nutrition policies,
• the Wapello Wellness Committee will meet on a semi-annual basis to assess the school district's nutrition and physical activity environments and practices.

Policy Review

To help with the initial development of the school district’s wellness policies, each school in the school district will conduct a baseline assessment of the school’s existing nutrition and physical activity environments and practices. The results of those school-by-school assessments will be compiled at the school district level to identify and prioritize needs.

Assessments will be repeated every three (3) years to help review policy compliance, assess progress and determine areas in need of improvement. As part of that review, the school district will review the nutrition and physical activity policies and practices and the provision of an environment that supports healthy eating and physical activity. The school district, and individual schools within the school district will, revise the wellness policies and develop work plans to facilitate their implementation.