_____________________________       ___/___/___            _________________     ___/___/___
Student's Name (Last), (First)  (Middle)      Birthday                    School                                        Date

 

In order for a student to self-administer medication for asthma or any airway constricting disease:

• Parent/guardian provides signed, dated authorization for student medication self-administration.
• Physician (person licensed under chapter 148, 150, or 150A, physician, physician's assistant, advanced registered nurse practitioner, or other person licensed or registered to distribute or dispense a prescription drug or device in the course of professional practice in Iowa in accordance with section 147.107, or a person licensed by another state in a health field in which, under Iowa law, licensees in this state may legally prescribe drugs) provides written authorization containing:
  
  • purpose of the medication,
  • prescribed dosage,
  • times or;
  • special circumstances under which the medication is to be administered.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.
• Authorization is renewed annually.  If any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.

Provided the above requirements are fulfilled, a student with asthma or other airway constricting disease may possess and use the student's medication while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before-school or after-school care on school-operated property. If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed.

Pursuant to state law, the school district or accredited nonpublic school and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district or nonpublic school is to incur no liability, except for gross negligence, as a result of self-administration of medication by the student as established by Iowa Code § 280.16.

 

                                                                                                                                               
Medication              Dosage        Route                                              Time

 

                                                                                                                                               
Purpose of Medication & Administration /Instructions

 

                                                                                                            /            /          
Special Circumstances                                                               Discontinue/Re-Evaluate/Follow-up Date

 

                                                                                                            /     /            
Prescriber’s Signature                                                                Date

 

                                                                                                                                               
Prescriber’s Address                                                                 Emergency Phone

• I request the above named student possess and self-administer asthma or other airway constricting disease medication(s) at school and in school activities according to the authorization and instructions.
• I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or for supervising, monitoring, or interfering with a student's self-administration of medication
• I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.
• I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.
• I agree the information is shared with school personnel in accordance with the Family Education Rights and Privacy Act (FERPA).
• I agree to provide the school with back-up medication approved in this form.
• (Student maintains self-administration record.) (Note: This bullet is recommended but not required.)

 

 

                                                                                                            /            /          
Parent/Guardian Signature                                                         Date
(agreed to above statement)                              

 

                                                                                                                                               
Parent/Guardian Address                                                           Home Phone

 

                                                                                                                                               
                                                                                                Business Phone

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               
Self-Administration Authorization Additional Information                                                  

 

_________________________________            ___/___/___            _________________     ___/___/___
Student's Name (Last), (First),  (Middle)                 Birthday                     School                                        Date

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer medication and/or provide the health service.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container.
• The medication label contains the student’s name, name of the medication, directions for use, and date.
• Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.

                                                                                                                                                             
Medication/Health Care               Dosage                    Route                      Time at School

                                                                                                                                               

                                                                                                                                               
Administration instructions

                                                                                                                                               

                                                                                                                                               
Special Directives, Signs to Observe and Side Effects

            /           /          
Discontinue/Re-Evaluate/Follow-up Date

                                                                                                /           /           
Prescriber’s Signature                                                    Date

                                                                                                                                   
Prescriber's Address                                                      Emergency Phone

I request the above named student carry medication at school and school activities, according to the prescription, instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided to the Family Education Rights and Privacy Act (FERPA).  I agree to coordinate and work with school personnel and prescriber when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.

 

                                                                                                            /            /          
Parent's Signature                                                                      Date

                                                                                                                                   
Parent's Address                                                                        Home Phone

                                                                                                                                   
Additional Information                                                              Business Phone

                                                                                                                                                                       

                                                                                                                                               

                                                                                                                                               
Authorization Form

 

CONCISE DESCRIPTIONS AND RECOMMENDATIONS FOR EXCLUSION OF CASES FROM SCHOOL

DISEASE *Immunization is available	Usual Interval Between Exposure and First Symptoms of Disease	MAIN SYMPTOMS	Minimum Exclusion From School
CHICKENPOX	13 to 17 days	Mild symptoms and fever.  Pocks are "blistery."  Develop scabs, most on covered parts of body.	7 days from onset of pocks or until pocks become dry
CONJUNCTIVITIS (PINK EYE)	24 to 72 hours	Tearing, redness and puffy lids, eye discharge.	Until treatment begins or physician approves readmission.
ERYTHEMIA INFECTIOSUM (5TH DISEASE)	4 to 20 days	Usual age 5 to 14 years – unusual in adults.  Brief prodrome of low-grade fever followed by Erythemia (slapped cheek) appearance on cheeks, lace-like rash on extremities lasting a few days to 3 weeks.  Rash seems to recur.	After diagnosis no exclusion from school.
GERMAN MEASLES* (RUBELLA)	14 to 23 days	Usually mild.  Enlarged glands in neck and behind ears.  Brief red rash.	7 days from onset of rash.  Keep away from pregnant women.
HAEMOPHILUS MENINGITIS	2 to 4 days	Fever, vomiting, lethargy, stiff neck and back.	Until physician permits return.
HEPATITIS A	Variable – 15 to 50 (average 28 to 30 days)	Abdominal pain, nausea, usually fever.  Skin and eyes may or may not turn yellow.	14 days from onset of clinical disease and at least 7 days from onset of jaundice.
IMPETIGO	1 to 3 days	Inflamed sores, with puss.	48 hours after antibiotic therapy started or until physician permits retune.
MEASLES*	10 days to fever, 14 days to rash	Begins with fever, conjunctivitis, runny nose, cough, then blotchy red rash.	4 days from onset of rash.
MENINGOCOCCAL MENINGITIS	2 to 10 days (commonly 3 to 4 days	Headache, nausea, stiff neck, fever.	Until physician permits return.
MUMPS*	12 to 25 (commonly 18) days	Fever, swelling and tenderness of glands at angle of jaw.	9 days after onset of swollen glands or until swelling disappears.
PEDICULOSIS (HEAD/BODY LICE)	7 days for eggs to hatch	Lice and nits (eggs) in hair.	24 hours after adequate treatment to kill lice and nits.
RINGWORM OF SCALP	10 to 14 days	Scaly patch, usually ring shaped, on scalp.	No exclusion from school.  Exclude from gymnasium, swimming pools, contact sports.
SCABIES	2 to 6 weeks initial exposure; 1 to 4 days reexposure	Tinny burrows in skin caused by mites.	Until 24 hours after treatment.
SCARLET FEVER SCARLATINA STREP THROAT	1 to 3 days	Sudden onset, vomiting, sore throat, fever, later fine rash (not on face).  Rash usually with first infection.	24 hours after antibiotics started and no fever.
WHOOPING COUGH* (PERTUSSIS)	7 to 10 days	Head cold, slight fever, cough, characteristic whoop after 2 weeks.	5 days after start of antibiotic treatment.

Readmission to School – It is advisable that school authorities require written permission from the health officer, school physician or attending physician before any pupil is readmitted to class following any disease which requires exclusion, not mere absence, from school.

 

While the school district is not responsible for reporting, the following infectious diseases are required to be reported to the state and local public health offices:

Acquired Immune                            Leprosy                                                            Rubella (German
  Deficiency Syndrome                  Leptospirosis                                                     measles)
  (AIDS)                                                 Lyme disease                                                 Rubeola (measles)
Amebiasis                                            Malaria                                                              Salmonellosis
Anthrax                                                  Meningitis                                                       Shigellosis
Botulism                                                   (bacterial or viral)                                     Tetanus
Brucellosis                                            Mumps                                                             Toxic Shock Syndrome
Campylobacteriosis                          Parvovirus B 19                                           Trichinosis
Chlamydia trachomatis                     infection (fifth                                             Tuberculosis
Cholera                                                      disease and other                                      Tularemia
Diphtheria                                                complications)                                            Typhoid fever
E. Coli 0157:h7                                  Pertussis                                                            Typhus fever
Encephalitis                                          (whooping cough)                                       Venereal disease
Giardiasis                                              Plague                                                                 Chancroid
Hepatitis, viral                                    Poliomyelitis                                                   Gonorrhea
  (A,B, Non A-                                     Psittacosis                                                         Granuloma Inguinale
  Non-B, Unspecified)                     Rabies                                                                 Lymphogranuloma
Histoplasmosis                                   Reye's Syndrome                                         Venereum
Human Immunodeficiency          Rheumatic fever                                             Syphilis
  Virus (HIV) infection                    Rocky Mountain                                           Yellow fever
  other than AIDS                                    spotted fever
Influenza                                                Rubella (congenital
Legionellosis                                          syndrome)                                                           

Any other disease which is unusual in incidence, occurs in unusual numbers of circumstances, or appears to be of public health concern, e.g., epidemic diarrhea, food or waterborne outbreaks, acute respiratory illness.

 

NOTE:  Be sure to mail the appropriate copies to both the state and local public health offices.  School districts must submit a report weekly if there are cases of mumps, chicken pox, erythema infectiosum, gastroenteritis, influenza-like illnesses and if the number is greater than 10 percent of the school district's enrollment.

 

Source:  Iowa Department of Public Health (1997).

REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1-800-362-2736)

Botulism		Poliomyelitis	Yellow Fever
Cholera		Rabies (Human)	Disease outbreaks of
Diphtheria		Rubella	any public health concern
Plague		Rubeola (measles)
REPORT ALL OTHER DISEASES BELOW.				WEEK ENDING
See other side for list of reportable infectious diseases.
DISEASE	PATIENT				COUNTY OR CITY	DOB		SEX
	Name                                                                                 Parent (If applicable)
	Address
	Attending Physician
	Name                                                                                 Parent (If applicable)
	Address
	Attending Physician
	Name                                                                                 Parent (If applicable)
	Address
	Attending Physician
	Name                                                                                 Parent (If applicable)
	Address
	Attending Physician
	Name                                                                                 Parent (If applicable)
	Address
	Attending Physician

 

Reporting Physician, Hospital, or Other Authorized Person

Address

Remarks:

 

FOR SCHOOLS ONLY:  Report over 10% absent only.  Total enrollment:
	Monday	Tuesday	Wednesday	Thursday	Friday
No. Absent
% of Enrollment
REPORT NUMBER OF CASES ONLY                                       Chickenpox                                                                                                         Gastroenteritis                                     Erythema infectiosum (5th Disease                      Influenza-like illness (URI)

 

Some students who require special education need special health services in order to participate in the educational program.  These students will receive special health services in accordance with their individualized educational program.

 

A.    Definitions

"Assignment and delegation" - occurs when licensed health personnel, in collaboration with the education team, determine the special health services to be provided and the qualifications of individuals performing the health services.  Primary consideration is given to the recommendation of the licensed health personnel.  Each designation considers the student's special health service.  The rationale for the designation is documented.  If the designation decision of the team differs from the licensed health professional, team members may file a dissenting opinion.

"Co-administration" - the eligible student's participation in the planning, management and implementation of the student's special health service and demonstration of proficiency to licensed health personnel.

"Educational program" - includes all school curricular programs and activities both on and off school grounds.

"Education team" - may include the eligible student, the student's parent, administrator, teacher, licensed health personnel, and others involved in the student's educational program.

"Health assessment" - health data collection, observation, analysis, and interpretation relating to the eligible student's educational program.

"Health instruction" - education by licensed health personnel to prepare qualified designated personnel to deliver and perform special health services contained in the eligible student's health plan.  Documentation of education and periodic updates are on file at school.

"Individual health plan" - the confidential, written, preplanned and ongoing special health service in the educational program.  It includes assessment, planning, implementation, documentation, evaluation and a plan for emergencies.  The plan is updated as needed and at least annually.  Licensed health personnel develop this written plan with the education team.

 

"Licensed health personnel" - includes licensed registered nurse, licensed physician, and other licensed health personnel legally authorized to provide special health services and medications.

"Prescriber" - licensed health personnel legally authorized to prescribe special health services and medications.

"Qualified designated personnel" - persons instructed, supervised and competent in implementing the eligible student's health plan.

"Special health services" - includes, but is not limited to, services for eligible students whose health status (stable or unstable) requires:

                  ·        Interpretation or intervention,

                  ·        Administration of health procedures and health care, or

                  ·        Use of a health device to compensate for the reduction or loss of a body function.

"Supervision" - the assessment, delegation, evaluation and documentation of special health services by licensed health personnel.  Levels of supervision include situations in which licensed health personnel are:

                  ·        physically present.

                  ·        available at the same site.

                  ·        available on call.

 

B.     Licensed health personnel will provide special health services under the auspices of the school.  Duties of the licensed personnel include the duty to:

        ·        Participate as a member of the education team.

        ·        Provide the health assessment.

        ·        Plan, implement and evaluate the written individual health plan.

        ·        Plan, implement and evaluate special emergency health services.

        ·        Serve as liaison and encourage participation and communication with health service agencies and individuals providing health care.

        ·        Provide health consultation, counseling and instruction with the eligible student, the student's parent and the staff in cooperation and conjunction with the prescriber.

        ·        Maintain a record of special health services.  The documentation includes the eligible student's name, special health service, prescriber or person authorizing, date and time, signature and title of the person providing the special health service and any unusual circumstances in the provision of such services.

        ·        Report unusual circumstances to the parent, school administration, and prescriber.

        ·        Assign and delegate to, instruct, provide technical assistance and supervise qualified designated personnel.

        ·        Update knowledge and skills to meet special health service needs.

 

C.     Prior to the provision of special health services the following will be on file:

        ·        Written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated.

        ·        Written statement by the student's parent requesting the provision of the special health service.

        ·        Written report of the preplanning staffing or meeting of the education team.

        ·        Written individual health plan available in the health record and integrated into the IEP or IFSP.

 

D.    Licensed health personnel, in collaboration with the education team, will determine the special health services to be provided and the qualifications of individuals performing the special health services.  The documented rationale will include the following:

        ·        Analysis and interpretation of the special health service needs, health status stability, complexity of the service, predictability of the service outcome and risk of improperly performed service.

        ·        Determination that the special health service, task, procedure or function is part of the person's job description.

        ·        Determination of the assignment and delegation based on the student's needs.

        ·        Review of the designated person's competency.

        ·        Determination of initial and ongoing level of supervision required to ensure quality services.

 

E.     Licensed health personnel will supervise the special health services, define the level of supervision and document the supervision.

 

F.     Licensed health personnel will instruct qualified designated personnel to deliver and perform special health services contained in the eligible individual health plan.  Documentation of instruction and periodic updates are on file at school.

 

G.    Parents will provide the usual equipment, supplies and necessary maintenance for such.  The equipment is stored in a secure area.  The personnel responsible for the equipment are designated in the individual health plan.  The individual health plan will designate the role of the school, parents, and others in the provision, supply, storage and maintenance of necessary equipment.

 

The school district will provide nutrition education and engage in nutrition promotion that:

• is offered at each grade level as part of a sequential, comprehensive, standards-based program designed to provide students with the knowledge and skills necessary to promote and protect their health;
• includes enjoyable, developmentally appropriate, culturally relevant participatory activities, such as contests, promotions, taste-testing, farm visits and school gardens;
• promotes fruits, vegetables, whole-grain products, low-fat and fat-free dairy products, healthy food preparation methods and health-enhancing nutrition practices; and
• emphasizes caloric balance between food intake and physical activity.

 

Daily Physical Education

The school district will provide physical education that:

• is for all students in grades K-12 for the entire school year;
• is taught by a certified physical education teacher;
• includes students with disabilities, students with special health-care needs may be provided in alternative educational settings; and,
• engages students in moderate to vigorous activity during at least 50 percent of physical education class time.

 

Daily Recess

Elementary schools should provide recess for students that:

• is at least 30 minutes a day;
• is preferably outdoors; and,
• encourages moderate to vigorous physical activity verbally and through the provision of space and equipment.
• discourages extended periods (i.e., periods of two or more hours) of inactivity.

When activities, such as mandatory school-wide testing, make it necessary for students to remain indoors for long periods of time, schools should give students periodic breaks during which they are encouraged to stand and be moderately active.

 

Physical Activity and Punishment

Employees should not use physical activity (e.g., running laps, pushups) or withhold opportunities for physical activity (e.g., recess, physical education) as punishment.

 

Physical Activity Opportunities after School

After-school child care and enrichment programs will provide and encourage—verbally, and through the provision of space, equipment and activities—daily periods of moderate to vigorous physical activity for all participants. 

 

Note – Iowa law now requires elementary students, K-5, to have 30 minutes of physical activity, not physical education, per day.  This requirement can be met through a combination of PE, recess, classroom and other activities.  Middle and high school students must have at least 120 minutes of physical activity per week.  Again this is not just physical education but can be met with a combination of PE, school and non-school sponsored athletics and other activities where the body is exerted.  Should a student wish to meet the requirement outside of school, the student and school district must have an agreement detailing the outside activity.    

  

In 2008, the Iowa Legislature enacted “the Healthy Kids Act,” requiring that all students in grades 6 – 12 engage in physical activity for a minimum of 120 minutes per week in which there are at least five days of school. The law also requires that we monitor how students fulfill this requirement.

Please fill out the items below, sign (both student and parent/guardian), and return to the school by ____________.

If you have any questions, call: 1-515-373-6619.                                                                              (date)

 

 

Name of Student: ___________________________________________   Grade (___________):_____________
                                                                                                                          School year

School activities that student will be involved in during the __________ school year (include estimate of minutes per week):

 

          FALL                                                       WINTER                                                                  SPRING

Cross country		Basketball		Track
Football		Wrestling		Golf
Volleyball		Bowling		Tennis
Swimming		Swimming (boys)		Soccer
Marching band		Show choir		Baseball
Cheerleading		Cheerleading		Softball
Drill team		Drill team		Pom squad
Trapshooting
Other* (what, when, how many minutes per week):

 

*   Non-school activities (may include non-school sport teams, gymnastics, dance, individualized exercise program, etc.) that student will be involved in during the ____________ school year.                          

 

Signature of Student: ___________________________________________  Date Signed: _______________________________

Signature of Parent/Guardian: _______________________________________________________________________________

Signature of Building Principal: ______________________________________________________________________________

 

Integrating Physical Activity into Classroom Settings

For students to receive the nationally recommended amount of daily physical activity and for students to fully embrace regular physical activity as a personal behavior, students need opportunities for physical activity beyond the physical education class.  Toward that end, the school district will:

• offer classroom health education that complements physical education by reinforcing the knowledge and self-management skills needed to maintain a physically active lifestyle and to reduce time spent on sedentary activities;
• discourage sedentary activities, such as watching television, playing computer games, etc. ; and,
• provide opportunities for physical activity to be incorporated into other subject lessons.

 

Communication with Parents

The school district will support parents’ efforts to provide a healthy diet and daily physical activity for their children.  The school district will:

• provide opportunities for students to share their healthy food practices with others in the school community;
• support parents’ efforts to provide their children with opportunities to be physically active outside of school; and,
• include sharing information about physical activity and physical education through a web site, newsletter, other take-home materials, special events or physical education homework.

 

Staff Wellness

The school district values the health and well-being of every staff member and will plan and implement activities and policies that support personal efforts by staff to maintain a healthy lifestyle.  The school should:

• develop, promote and oversee a multifaceted plan to promote staff health and wellness developed by the staff wellness committee.

 

School Meals

Meals served through the National School Lunch and Breakfast Programs will:

• be appealing and attractive to children;
• be served in clean and pleasant settings;
• meet, at a minimum, nutrition requirements established by local, state and federal law:
• offer a variety of fruits and vegetables;
• serve only low-fat (1%) and fat-free milk and nutritionally equivalent non-dairy alternatives (as defined by the USDA); and,
• ensure that half of the served grains are whole grain.

The school will:

• set guidelines for eating fruits and vegetables;
• set guidelines for  receiving extra portions; and
• share information about the nutritional content of meals with parents and students.  (The information could be made available on menus, a web site, on cafeteria menu boards, placards or other point-of-purchase materials.)

 

Breakfast

To ensure that all children have breakfast, either at home or at school, in order to meet their nutritional needs and enhance their ability to learn, schools will:

• operate the breakfast program, to the extent possible;
• arrange bus schedules and utilize methods to serve breakfasts that encourage participation, including serving breakfast in the classroom, “grab-and-go” breakfasts or breakfast during morning break or recess, to the extent possible;
• notify parents and students of the availability of the School Breakfast Program, where available; and,
• encourage parents to provide a healthy breakfast for their children through newsletter articles, take-home materials or other means.

 

Free and Reduced-Priced Meals

The school district will make every effort to eliminate any social stigma attached to, and prevent the overt identification of, students who are eligible for free and reduced-price meals.  Toward this end, the school district may:

• utilize electronic identification and payment systems; and
• promote the availability of meals to all students.

 

Qualification of Food Service Staff

Qualified nutrition professionals will administer the meal programs.  As part of the school district’s responsibility to operate a food service program, the school district will:

• provide continuing professional development for all nutrition professionals; and,
• provide staff development programs that include appropriate certification and/or training programs for child nutrition directors, nutrition managers and cafeteria workers, according to their levels of responsibility.

 

Celebrations

The school will evaluate their celebrations practices that involve food during the school day.  The school district will disseminate a list of healthy party ideas to parents and teachers.

 

Monitoring

The superintendent will ensure compliance with established school district-wide nutrition and physical activity wellness policies.

In each school:

• the principal will ensure compliance with those policies in the school and will report on the school’s compliance to the superintendent; and,
• food service staff, at the school or school district level, will ensure compliance with nutrition policies within food service areas and will report on this matter to the superintendent or principal.

In the school district:

• the school district will report on the most recent USDA School Meals Initiative (SMI) review findings and any resulting changes.  If the school district has not received a SMI review from the state agency within the past five years, the school district will request from the state agency that a SMI review be scheduled as soon as possible;
• the superintendent will develop a summary report every three years on school district-wide compliance with the school district’s established nutrition and physical activity wellness policies, based on input from schools within the school district; and,
• the report will be provided to the school board and also distributed to all school wellness committees, parent/teacher organizations, principals and health services personnel in the school district.

 

Policy Review

To help with the initial development of the school district’s wellness policies, each school in the school district will conduct a baseline assessment of the school’s existing nutrition and physical activity environments and practices.  The results of those school-by-school assessments will be compiled at the school district level to identify and prioritize needs.

Assessments will be repeated every three years to help review policy compliance, assess progress and determine areas in need of improvement.  As part of that review, the school district will review the nutrition and physical activity policies and practices and the provision of an environment that supports healthy eating and physical activity.  The school district, and individual schools within the school district will, revise the wellness policies and develop work plans to facilitate their implementation.