Medication Forms

Carry and Self Administer English
This form is used for 6th-12th grader to obtain permission to carry and self administer medications excluding controlled substances (ritalin, adderall)
Carry and Self Administer Espanol
This form is for 6th-12th grade students to obtain permission to carry and self administer medications excluding controlled substances (ritalin, adderall)
Non Prescription English
This form allows school staff to administer non prescription medication to a student. Parent or guardian must provide the medication to the school for their child(ren).
Non Prescription Espanol
This form allows school staff to administer non prescription medication to a student. Parent or guardian must provide the medication to the school for their child(ren).
Prescription English
This form allows school staff to administer prescription medication to students
Prescription Espanol
This form allows school staff to administer prescription medication to students
Inhaler English
This form must be completed by the prescribing health care provider and parent guardian to give permission to a student with asthma to use an inhaler, and/or keep the inhaler in their possession.
Inhaler Espanol
Emergency Allergy Action Plan (Epi-pen form)
This form is used when a student needs to have an Epi-pen kept at school in case of a potentially life threatening allergic reaction
Diabetes Individualized Student Plan
This form may be used for the health care provider to complete specific information regarding the student's diabetes needs at school.
Diabetes questionnaire Spanish
Seizure Questionnaire for parents
Please use this form to provide specific information about your child's seizure disorder and related needs at school. If your child needs an anti-seizure medication at school, you will need to also need to have a prescription medication form completed by the health care provider.
Seizure questionnaire Spanish
Health Concerns Questionnaire English
To help us meet your child's health related needs, please complete any section that applies to your child. Sign and return this form to your child's school annually and as needed. Contact your school nurse.
Cuestionario De Preocupaciones De Salud

School Board Policy

MONONA GROVE SCHOOL DISTRICT

Board Policy 453.4

ADMINISTERING MEDICATION TO STUDENTS

Medication should be administered to a student at home rather than at school whenever possible to limit the amount of disruption to the student’s day.  Medication may be administered by school personnel authorized in writing by the building principal, in accordance with state law and established procedures. Designated school personnel have the right to refuse to administer medication to a student when the parent/guardian has not complied with established requirements. No school personnel, except the School Nurse, shall be required to administer any medication to a student by any means other than ingestion. School personnel voluntarily accepting the responsibility of administering medication by any means other than ingesting (including inhalation, insertion into the eye, ear and/or nose, injections, rectally or by g-tube) shall be provided appropriate instruction from the School Nurse. These nursing procedures must be delegated to school personnel under the general direction of a registered nurse, pursuant to state law and regulations.

No medication may be administered by school personnel without the following instructions/consent being on file at the school:

  1. Written instructions from the student’s practitioner and written permission from the student’s parent/guardian must be on file before prescription medication may be administered by authorized school personnel.
  2. Written instructions and written permission from the student’s parent/guardian must be on file before non-prescription medication (over-the-counter medication) may be administered by authorized school personnel.

A student may possess and self-administer an inhaler while in school, at a school-sponsored activity or under the supervision of a school authority if both of the following conditions are true:

  1. The student uses the inhaler before exercise to prevent the onset of asthmatic symptoms or uses the inhaler to alleviate asthmatic symptoms; and
  2. The student has provided the building principal with written approval of the student’s physician and, if the student is a minor, the written approval of the student’s parent/guardian.

Possession and Self-Administration of Medication

In addition to possessing and self-administering an inhaler as specified above, middle and high school students may possess and self-administer non-prescription medication or certain prescription medication. All controlled substances such as Ritalin, Dexedrine and Adderall must be stored and administered by school personnel. Such a student shall carry a small amount of the medication and must not share the medication with other students. Parents/guardians should provide written permission for their child to carry and self-administer a medication at school. A student’s ability to manage his/her own medication may be evaluated by building staff after consultation with the School Nurse. The parent/guardian may be asked to reconsider the appropriateness of the student administering his/her own medication without supervision.

  • Monona Grove School District
  • 5301 Monona Drive
  • Monona, WI 53716
  • Phone: (608) 221-7660
  • Fax: (608) 221-7688
  • Monona Grove School District
  • 5301 Monona Drive
  • Monona, WI 53716
  • Phone: (608) 221-7660
  • Fax: (608) 221-7688

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