Medication administration form pdf 2026

1. Click ‘Get Form’ to open the medication administration form in the editor.
2. Begin by entering today’s date at the top of the form. This helps keep track of when the request is made.
3. Fill in the student’s name (Last, First, MI) and their school. This ensures that the medication is administered to the correct student.
4. Provide the student’s date of birth in the specified format (Mo/Day/Yr) for accurate identification.
5. Detail the student’s diagnosis and specify the medication being prescribed, including dosage and time of administration.
6. Indicate the route of administration and any specific instructions related to how the medication should be given.
7. Enter both start and end dates for when the medication should be administered, ensuring compliance with medical guidelines.
8. If applicable, include the Diagnostic ICD-9 Code for Norfolk Public Schools only.
9. Have a healthcare provider print their name, sign, and provide their contact number for verification purposes.
10. Finally, ensure that a parent or legal guardian signs at the bottom, granting permission for school personnel to administer the medication as prescribed.

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