HARRISVILLE CENTRAL SCHOOL

HARRI= SVILLE CENTRAL SCHOOL

2011-2012

NURSE MEDICATION DISPENSING FORM

New York State Education Department requires the schoo= l to have on file permission signed by the parent/guardian and the child’s physician before we can administer any medication to your child. This includes both prescription and non-prescription (over the counter) medicati= ons. After consultation with the school physician, the following non-prescription medications will be available in = our Health Office for use by the school nurse.

Please mark an X to the left of any medication you DO NOT wish your child to receive= .

____ Acetaminophen

For age every 4 hours as needed for mild aches, pain, headache, toothache, menstrual cramps, fever

____ Bactracin

Antibiotic ointment for abrasions & superficial = wounds

____ Chloroseptic Spray<= /p>

Sore throats, mouth pain

____ Cinder Suds

Foam soap lifts dirt and debris from minor wounds

____ Cough Drops/Lozenges

Soothes throat, aids in preventing cough

____ Cramergesic

Muscle rub, like Bengay<= /p>

____ Diphenhydramine

Antihistamine like Benedryl: sneezing, runny nose, itchy throat, watery eyes

____ Foille Burn

Ointment or spray: sooths minor burns or sunburn

____ Glyoxide

Antiseptic oral cleanser: minor mouth or gum irritat= ions, soothes canker sores

____ Hydrogen Peroxide

To cleanse wounds

____ Ibuprofen

For age every 4 hours as needed for headache, , musculoskeletal complaints, menstrual cramps

____ Loratadine Tablets<= /p>

Antihistamine like Claritin: seasonal allergies, hiv= es, stuffy nose, sinus headache

____ Murine Tears

Lubricant eye drops, dry eyes

____ Ora-Jel

Toothache, mouth sores

____ Pepto Bismol

Heartburn, nausea, indigestion, diarrhea

____ Strawberry Ointment

Antiseptic to seal out infection & inhibit bacte= rial growth of minor wounds

____ Tetrahydrozoline

Eye drops: like Visine, relieving eye redness

____ Tums

Heartburn, sour stomach, ingestion

____ Tussin DM

Cough suppressant expectorant: controls cough, loose= ns chest congestion

____ Vaseline

To lubricate chapped lips

____ Waterless Hand=

        &nbs= p; Sanitizer

To cleanse hands when soap & water are not avail= able

____ Other _______________________________________________________ as provided by pare= nt

I give permission for the use of all of the above medications in the treatment of my child EXCEPT THE ONES THAT ARE MARKED WITH AN X= , as deemed appropriate by the school nurse. This permission will remain in effect for the 2011-2012 school year unless I notify the school in writing.=

STUDENT NAME _____________________________ DATE O= F BIRTH _________        =

Both

Signatures

Are

Required.

    &n= bsp;            = ;            &n= bsp;      _________________________________= _______        &= nbsp;       _________________

   &nbs= p;            &= nbsp;           &nbs= p;       PARENT/GUARDIAN SIGNATURE     &nbs= p;            &= nbsp;           &nbs= p;           DATE<= span style=3D'mso-tab-count:1'>

   &nbs= p;            &= nbsp;           &nbs= p;       _____________________________= ___________        &= nbsp;       _________________

   &nbs= p;            &= nbsp;           &nbs= p;       PHYSICIAN’S SIGNATURE     &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;         DATE

____ Acetaminophen	For age every 4 hours as needed for mild aches, pain, headache, toothache, menstrual cramps, fever
____ Bactracin	Antibiotic ointment for abrasions & superficial = wounds
____ Chloroseptic Spray<= /p>	Sore throats, mouth pain
____ Cinder Suds	Foam soap lifts dirt and debris from minor wounds
____ Cough Drops/Lozenges	Soothes throat, aids in preventing cough
____ Cramergesic	Muscle rub, like Bengay<= /p>
____ Diphenhydramine	Antihistamine like Benedryl: sneezing, runny nose, itchy throat, watery eyes
____ Foille Burn	Ointment or spray: sooths minor burns or sunburn
____ Glyoxide	Antiseptic oral cleanser: minor mouth or gum irritat= ions, soothes canker sores
____ Hydrogen Peroxide	To cleanse wounds
____ Ibuprofen	For age every 4 hours as needed for headache, , musculoskeletal complaints, menstrual cramps
____ Loratadine Tablets<= /p>	Antihistamine like Claritin: seasonal allergies, hiv= es, stuffy nose, sinus headache
____ Murine Tears	Lubricant eye drops, dry eyes
____ Ora-Jel	Toothache, mouth sores
____ Pepto Bismol	Heartburn, nausea, indigestion, diarrhea
____ Strawberry Ointment	Antiseptic to seal out infection & inhibit bacte= rial growth of minor wounds
____ Tetrahydrozoline	Eye drops: like Visine, relieving eye redness
____ Tums	Heartburn, sour stomach, ingestion
____ Tussin DM	Cough suppressant expectorant: controls cough, loose= ns chest congestion
____ Vaseline	To lubricate chapped lips
____ Waterless Hand= &nbs= p; Sanitizer	To cleanse hands when soap & water are not avail= able