Form 316-1

Request For The Administration Of Medication Or Medical Treatment


1.   Name of Medication and/or Treatment

2.   Purpose of Medication and/or Treatment

3.   Time Intervals for Administration

4.   Dosage and Procedure for Administration

5.   Possible Side Effects

6.   Procedure to Follow in Case of Adverse Reaction

7.   Special Storage Instructions for the Medication

8.   Security Requirements to Prevent Risk to Others

9.   Termination Date for Administration

10.   Authorization and Procedure for Student Self-Administration

11.   Training Required

12.   Medication to be Administered by:

     
Signature of Parent/Legal Guardian   Date
     
Signature of Doctor   Date
     
Signature of Principal:   Date
     
Signature of Individual Administering the Treatment/Medication:   Date