Achsd 2025

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The document is a Medication Authorization form for the Coulee-Hartline School District, allowing for the administration of oral and emergency injected medications to students during school hours. It requires information from a licensed health professional regarding the student's diagnosis, medication details, potential side effects, and permissions from a parent or guardian for self-administration and carrying of medications.

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Click ‘Get Form’ to open the achsd in the editor.
Begin by entering the student's name and birth date in the designated fields. Ensure accuracy for proper identification.
Select the school from the dropdown menu, and specify the student's grade level.
In the Licensed Health Professional (LHP) section, provide details about the diagnosis or reason for medication. Indicate severity by checking mild, moderate, or severe.
List the medication name, dosage, method of administration, and frequency. If PRN (as needed), describe indications clearly.
For Epi-Pens, outline signs or symptoms that necessitate use. Confirm if the student can travel on field trips over 30 minutes away from emergency medical response.
Complete possible side effects of medication and confirm self-administration capabilities for inhalers and Epi-Pens.
Have both the LHP and parent/guardian sign and date their respective sections to authorize medication administration.

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