NY Asthma Medication Administration Form 2023-2025 free printable template
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ASTHMA MEDICATION ADMINISTRATION FORM PROVIDER MEDICATION ORDER FORM Office of School Health School Year Student Last Name First Name Middle Initial Male Female Date of Birth / / M M D D Y Y Y Y Attach Student Photo To This Sheet OSIS DOE District School Name Number Address and Borough Grade The Following Section Completed By Student s HEALTH CARE PRACTITIONERS Diagnosis Asthma Control see NAEPP Guidelines Well Controlled Not Controlled Unknown Severity see NAEPP Guidelines Intermittent...
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How to fill out NY Asthma Medication Administration Form
01
Obtain the NY Asthma Medication Administration Form from your school or healthcare provider.
02
Fill in the student's name and date of birth at the top of the form.
03
Provide the name of the medication and the dosage prescribed by the healthcare provider.
04
Indicate the frequency and method of administration (e.g., during school hours, before gym class).
05
Include any specific instructions for use or storage of the medication.
06
Have the form signed by the student's parent or guardian.
07
Ensure that the healthcare provider also signs the form to verify the prescription.
08
Submit the completed form to the school nurse or designated school official.
Who needs NY Asthma Medication Administration Form?
01
Students diagnosed with asthma who require medication during school hours.
02
Parents or guardians of students needing to manage asthma symptoms at school.
03
Healthcare providers prescribing asthma medication for students attending school.
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What is NY Asthma Medication Administration Form?
The NY Asthma Medication Administration Form is a document used in New York State that allows students with asthma to have their medication administered by school staff during school hours or school-sponsored activities.
Who is required to file NY Asthma Medication Administration Form?
Parents or guardians of students with asthma are required to file the NY Asthma Medication Administration Form, along with a healthcare provider's authorization, to ensure that their child can receive necessary asthma medications at school.
How to fill out NY Asthma Medication Administration Form?
The form should be filled out by the parent or guardian in collaboration with the child's healthcare provider, providing necessary details about the student, the asthma medication prescribed, dosages, and administration instructions.
What is the purpose of NY Asthma Medication Administration Form?
The purpose of the NY Asthma Medication Administration Form is to provide written consent and instructions for school personnel to administer asthma medication to students, ensuring their health and safety while at school.
What information must be reported on NY Asthma Medication Administration Form?
The form must report the student's name, date of birth, details of the asthma condition, the specific medication prescribed, dosage, frequency of administration, and information about any potential side effects.
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