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Dear parent or guardian

New Jersey Administrative Code 6A: Chapter 16 requires each Asthmatic Student in our school district to have an Individual Asthma Treatment Care Plan. Your child has been identified as an Asthmatic and requires your physician to submit an Asthma Treatment Care Plan for your child. This Treatment Plan will be utilized in the event your child has an asthmatic attack at school. I have developed a sample Asthma Treatment Plan that may be considered for your child. Please take this packet to your physician for their review and completion. Your doctor may wish to use this Treatment Plan or develop another one for your child. Please have your child’s Treatment Plan brought back to the school nurse’s office within two weeks. In addition, there are two forms regarding medication administration which are to be completed by yourself and your physician. The first form: AUTHORIZATION FOR ADMINISTRATION OF PRESCRIPTION MEDICATION IN SCHOOL provides permission for school district to administer medication to your child. This should be completed for all children with asthma. The second form: SELF ADMINISTRATION OF LIFE THREATENING MEDICATIONS, allows your child to carry and administer his/her own asthma medication. Please understand that this request may not be appropriate for your child. I urge you to discuss this with your medical provider and return this form to the School Nurse if appropriate. If you have any questions please do not hesitate to contact the School Nurse. Ronald M Frank, MD School Medical Inspector Sean Cook, M.D.
Ronald M. Frank, M.D.
Jennifer E. Wiseman, MSN, FNP
NJ state law states “that each student authorized to use asthma medication pursuant to N.J.S.A. 18A:40-12.3, or a nebulizer, have an asthma treatment plan prepared by the student’s physician, which shall identify at a minimum, asthma triggers and an individualized healthcare plan, pursuant to N.J.A.C. 6A:16-2.1(e), for meeting the medical needs of the student while attending school or a school-sponsored event.” (N.J.A.C. 6A:16-2.3(g)3) Your patient has been identified to be in need of an Individual Asthma Treatment Plan. In an effort to simplify the paperwork for you, I have developed an Asthma Treatment Plan for your review. This is an emergency care plan that will be utilized in the event your patient has an asthmatic attack while at school. Each school maintains a nebulizer, supplies, peak flow meters and unit dose Albuterol nebulizer solution. Please review this flow sheet/ treatment plan. If you are interested in using this plan for your child, please complete the appropriate sections and return the form. If this plan is not acceptable for your patient, please submit an alternate plan. The alternate plan must contain information regarding known asthmatic triggers, current medication and emergency treatment instructions. If you have any questions, please contact me at my office. Ronald M Frank, MD School Medical Inspector Individual Asthma Treatment Plan
Student’s Name: ___________________________ Grade: _______________ Student’s DOB: ____________________________ Date: ________________ Physician’s Name: ______________________________ Physician’s Telephone Number: ___________________ Known Triggers:
___Chalk dust
___Foods:_________________________________ ___Other:_________________________________ Current Medications :( meds/ dosages/frequency)
Treatment instructions:
1. In the event of an acute asthmatic attack, the student will report to the school nurse. If the child has previously been designated to self-administer an MDI, they will be allowed to utilize their MDI until medically evaluated by the school nurse. Parent/Guardian will be notified. 2. If the student requires treatment for Asthma, administer Albuterol 0.083% 2.5mg in 3ml unit dose Nebulizer Solution every 15min as needed for up to 3 doses. The student’s disposition as to whether the student can remain in school or be sent for medical evaluation will be dependent on treatment outcome. 3. If a student who remains at school develops a flare-up of symptoms later that day, treatment protocol will be re-instituted; the student will not be allowed to remain in school and must be referred to their primary physician or ER depending on the severity of symptoms. 4. If respiratory distress is part of an anaphylactic reaction, administer Epinephrine and Diphenhydramine as per the school’s standing orders or individual student orders if available. Call EMS ASAP. Signature of Physician: ______________________________________Date:_______________ AUTHORIZATION FOR ADMINISTRATION OF
PRESCRIPTION MEDICATION IN SCHOOL
The following section is to be completed by the PARENT/GUARDIAN:
I request that my child be assisted in taking the medication described below at school by the School Nurse or other individuals authorized to administer medication to students in school pursuant to N.J.A.C:.6A:16-2.3. I understand the ultimate responsibility for administration of the medication is mine, and I am fully aware that the duties of the school nurse and others may require their presence at another location at the time that the medication is needed. I understand that the school district, agents and its employees shall incur no liability as a result of any condition or injury arising from the administration or lack of administration of the medication prescribed on this form. I indemnify and hold harmless the School District, its agents and employees against any claims arising out of administration or lack of administration of this medication. RECOMMENDATIONS ARE EFFECTIVE FOR ONE (1) SCHOOL YEAR ONLY
AND MUST BE RENEWED ANNUALLY
The following section is to be completed by the PHYSICIAN:
Diagnosis for which medication is give: _______________________________________________________________________ Name of medication: ______________________________________________________________________________________ Dose: __________________________________________________________________________________________________ What time should the daily medication should be given? ______________________ ___________________________________ If medicine is be given “WHEN NEEDED”, describe indications: ____________________________________________________ How soon can PRN medicine be repeated? ____________________________________________________________________ List significant side effects: _________________________________________________________________________________ Any restrictions or limitations: _______________________________________________________________________________ PLEASE CHECK THE APPROPRIATE OPTION
** RE: CLASS TRIPS When a parent is unable to attend a class trip:
_____________ YES, the prescribed dose can be withheld on the day of the class trip.
_____________ YES, the time to be given can be adjusted with the parent/guardian.
_____________ NO, this medication must be given to the child at the scheduled time.
I verify that this child is free from contagion and this medication is necessary for the student to fully participate in the school educational plan. This form must be individually completed for all prescribed medications.
Medications are to be brought to school by the parent in the original container, labeled appropriately by the pharmacy.
All medications will be kept in a locked storage area.
It may not be possible to administer daily medication on half session days, early dismissal days or delayed opening days.
Parent/guardian will be notified if the daily medication could not be given to the student.
READINGTON TOWNSHIP PUBLIC SCHOOLS
SELF ADMINISTRATION OF MEDICATIONS
FOR LIFE THREATENING CONDITIONS
N.J.S.A. Title 18A:40-12.3 directs that students may be permitted to self administer medications for asthma or other
potentially life-threatening illnesses provided proper procedures are followed. This form must be individually completed for
all prescribed medications.
The following section is to be completed by the PARENT/GUARDIAN:
________________________________________________________________________________________________

Student’s
Grade/Team
I request that my child be ALLOWED to carry the following medication _____________________ for self-administration In school pursuant to N.J.A.C:.6A:16-2.3. I give permission for my child to self-administer medication, as prescribed on this form for the current school year as I consider him/her to be responsible and capable of transporting, storing and self-administration of the medication. I understand that the school district, agents and its employees shall incur no liability as a result of any condition or injury arising from the self-administration by the student of the medication prescribed on this form. I indemnify and hold harmless the School District, its agents and employees against any claims arising out of self-administration or lack of administration of this medication by the student. _________________________________ _______________________________ RECOMMENDATIONS ARE EFFECTIVE FOR ONE (1) SCHOOL YEAR ONLY
AND MUST BE RENEWED ANNUALLY
The following section is to be completed by the PHYSICIAN:

Potential life-threatening Diagnosis for which medication is given: ____________________________________________
Name of medication: _______________________________________________________________________________
Dosage: __________________________ Route: __________________Frequency: _____________________________
If medicine is be given “WHEN NEEDED”, describe indications/symptoms: _____________________________________
_________________________________________________________________________________________________
How soon can the medicine be repeated? _______________________________________________________________
List significant side effects: ___________________________________________________________________________
Any restrictions or limitations: _________________________________________________________________________
I verify that the child above requires this medication and
a. This student has been instructed in and is capable of proper method of self-administration of the medication prescribed
above.
b. This student understands the purpose, appropriate method and frequency of use of the medication prescribed above.
c. The student’s medication, if ingested by someone other than the student will not cause severe illness or death.
_________________________________________________________________________________________________
Physician’s
_________________________________________________________________________________________________ Physician’s
________________________________________________________________
Approved By School Nurse: _____________________________________________________
Signature
School District: ______________________________________ School Year: _____________
Approved by school MD_________________________________________________________

Signature
V04232009

Source: http://www.readington.k12.nj.us/cms/lib07/NJ01000244/Centricity/Domain/28/SELF_ADMINISTRATION_OF_MEDICATIONS_v3.pdf

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