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Exhibit JGCD-E(1): Medication

JGCD-E(1) · Exhibit · Adopted 06/13/2011

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Exhibit                                                                                                           Descriptor Code
Medicines                                                                                                         JGCD-E

                                               DEKALB COUNTY SCHOOLS
                                              STUDENT HEALTH SERVICES
                 PHYSICIAN’S REQUEST FOR ADMINISTRATION OF MEDICATION
                        IN SCHOOL BUILDING DURING SCHOOL HOURS
                                  Must be Completed Annually
1.   To keep this child in optimal health and to help maintain school performance, it is necessary that medication be given
     during school hours.
2.   Nurses and other designated school personnel can assist with self-administration of medication during school hours.
3.   In order for medication to be self administered at school, this form must be completed by licensed physician and at least
     one guardian/parent and be returned to school.

School:

Name of child:                                                                         DOB

Diagnosis:                                                                             Infectious              Noninfectious
                                                                                                (Please check one)
Allergies:

Name of medication:                                                                               Color, if applicable
                                                (Include trade name)

Route of Administration:
Form of medication to be given (specify below):
        tablet           pill         capsule        liquid         inhalation          injection**                      other
** No injection will be given except in extreme emergency, such as allergy to wasp or bee sting or the like.

Dosage (amount to be given):                                      Frequency:

Side Effects:


Physician’s Signature                                   (date)                 Physician’s Name (print or type)

                                                                       /
Physician’s Office Phone/Fax#

______________________________________________________________________________________________________

*This is your permission to give medication to my child named above as requested by the physician.

                                                                                                           /
Parent’s Signature                                      (date)                       Home Phone#           Work Phone#

                                       /
Pager/Cell#                                                                          Email address

*MEDICATION MUST BE DELIVERED TO SCHOOL BY A RESPONSIBLE ADULT IN THE CONTAINER IN
WHICH IT WAS DISPENSED BY THE PRESCRIBING PHYSICIAN, LICENSED PHARMACIST OR
PHARMACY.

Any unused and or expired portions of any medications that are not collected by the parent/guardian within one week
will be destroyed.                                                                                      Revised 3/22/11


11970262.1

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