Microsoft word - consent forms re managing medicines in schools.doc

ANNEX B: FORMS
Form 1
Emergency planning - request for an ambulance
Form 2 Healthcare
Parental agreement for school/setting to administer medicines Parental agreement for school/setting to administer medicines Parental agreement for school/setting to administer non- prescription analgesics
Form 3 D
Parental agreement for school/setting to administer non- prescription medicines on school visits
Form 4
Head teacher/Head of setting agreement to administer Record of medicine administered to an individual Record of medicines administered to all children Request for child to carry his/her own medicine Staff training record - administration of medicines Authorisation for administration of rectal diazepam
All forms set out below are examples that schools and settings may wish to
use or adapt according to their particular policies on administering medicines.

Consent Forms - Managing Medicines in Schools May 2008
FORM 1 - Contacting Emergency Services
Request for an Ambulance

Dial 999, ask for ambulance and be ready with the following information
Give your location as follows: (insert school/setting address) Give exact location in the school/setting (insert brief description) Give name of child and a brief description of child’s symptoms Inform Ambulance Control of the best entrance and state that the crew
Speak clearly and slowly and be ready to repeat information if asked
Put a completed copy of this form by the telephone
Consent Forms - Managing Medicines in Schools May 2008
FORM 2 - Healthcare Plan
CONTACT INFORMATION
Family contact 1
Family contact 2
Clinic/Hospital contact
Consent Forms - Managing Medicines in Schools May 2008 Describe medical needs and give details of child’s symptoms: Daily care requirements: (e.g. before sport/at lunchtime) Describe what constitutes an emergency for the child, and the action to take if this occurs: Who is responsible in an Emergency: (State if different for off-site activities) Consent Forms - Managing Medicines in Schools May 2008 Parental agreement for school/setting to administer medicine
The school/setting will not give your child medicine unless you complete and sign this form, and the school or setting has a policy that staff can administer medicine
Medicine
Name/Type of Medicine (as described on
the container):
Procedures to take in an Emergency:
Note: Medicines must be in the original container as dispensed by the
pharmacy
Consent Forms - Managing Medicines in Schools May 2008 Contact Details
I understand that I must deliver the medicine personally to [agreed member of staff] and accept that this is a service that the school/setting is not obliged to undertake. I understand that I must notify the school/setting of any changes in writing. Consent Forms - Managing Medicines in Schools May 2008 Parental agreement for school/setting to administer medicine
The school/setting will not give your child medicine unless you complete and sign this form, and the school or setting has a policy that staff can administer medicine. How much to give ( i.e. dose to be given) Number of tablets/quantity to be
given to school/setting

Note: Medicines must be in the original container as dispensed by the
pharmacy

Daytime phone no. of parent or adult contact [name of member of staff]: The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school/setting policy. I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped. Parent’s signature: If more than one medicine is to be given a separate form should be completed for each one.
Consent Forms - Managing Medicines in Schools May 2008 Parental agreement for school to administer occasional prescription
medication
e.g. amoxicillin, penicillin, eye drops etc

The school will not give your child medicine unless you complete and sign this form, and the school has a policy that staff can administer medicine. Daytime phone no. of parent or adult contact [name of member of staff]: I confirm that I have administered amoxicillin/penicillin/eye drops/other (circle as appropriate) without adverse effect to my child in the past. I give consent to school staff to administer amoxicillin/penicillin/eye drops/other (circle as appropriate) in accordance with the school policy. I will inform the school immediately, in writing, if my child subsequently is adversely affected by the medication prescribed. Consent Forms - Managing Medicines in Schools May 2008 Parental agreement for school to administer occasional non-prescription
medicine for school journeys or residential trips, e.g. travel sickness tablets,
antihistamines.

The school will not give your child medicine unless you complete and sign this form,
and the school has a policy that staff can administer medicine.
Number of tablets/quantity to be given
to school/setting

Note: Medicines must be in the original container, which must contain the
Patient Information Leaflet

Daytime phone no. of parent or adult contact [name of member of staff]: I confirm that I have administered this non-prescription medication, without adverse effect, to my child in the past. The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school staff administering medicine in accordance with the school policy. I will inform the school immediately, in writing, if my child subsequently is adversely affected by the above medication Parent’s signature: If more than one non-prescription medicine is to be given a separate form should be completed for each one. Consent Forms - Managing Medicines in Schools May 2008 Confirmation of the Head’s agreement to administer medicine

It is agreed that __________________ [name of child] will receive
_______________________ [quantity and name of medicine] every day at ___________________ [time medicine to be administered e.g. Lunchtime or __________________ [name of child] will be given/supervised whilst he/she takes their medication by __________________ [name of member of staff]. This arrangement will continue until____________________ [either end date of course of medicine or until instructed by parents]. [The Head teacher/Head of Setting/Named Member of Staff] Consent Forms - Managing Medicines in Schools May 2008 Record of medicine administered to an individual child
Consent Forms - Managing Medicines in Schools May 2008 Consent Forms - Managing Medicines in Schools May 2008 FORM 6
Record of medicines administered to all children

Date Child’s name Time Name of Batch Dose given Any reactions Signature Consent Forms - Managing Medicines in Schools May 2008 FORM 7
Request for child to carry his/her medicine
THIS FORM MUST BE COMPLETED BY PARENTS/GUARDIAN
If staff have any concerns discuss request with school healthcare
professionals
Procedures to be taken in an
emergency:

Contact Information

Relationship to child: I would like my son/daughter to keep his/her medicine on him/her for use as necessary. If more than one medicine is to be given a separate form should be completed for each one.
Consent Forms - Managing Medicines in Schools May 2008 Staff training record - administration of medicines
I confirm that ___________________________ [name of member of staff] has received the training detailed above and is competent to carry out any necessary treatment. I recommend that the training is updated (please state how often) Date: I confirm that I have received the training detailed above. Consent Forms - Managing Medicines in Schools May 2008 FORM 9
Authorisation for the administration of rectal diazepam

Name of School/Setting Bedgrove Infant School Hospital consultant


_________________ [name of child] should be given Rectal Diazepam____
mg. If he/she has a *prolonged epileptic seizure lasting over ____ minutes
*serial seizures lasting over __________________ minutes. An Ambulance should be called for *at the beginning of the seizure If the seizure has not resolved *after ______________ minutes. (* please delete as appropriate) Consent Forms - Managing Medicines in Schools May 2008
NB: Authorisation for the Administration of Rectal Diazepam

As the indications of when to administer the diazepam vary, an individual
authorisation is required for each child. This should be completed by the
child’s GP, Consultant and/or Epilepsy Specialist Nurse and reviewed
regularly. This ensures the medicine is administered appropriately.
The Authorisation should clearly state:
 when the diazepam is to be given e.g. after 5 minutes; and Included on the Authorisation Form should be an indication of when an ambulance is to be summoned. Records of administration should be maintained using Form 5 or similar
Consent Forms - Managing Medicines in Schools May 2008

Source: http://www.bedgroveinfantschool.co.uk/Parent%20area%20resources/Consent%20Forms%20re%20Managing%20Medicines%20in%20Schools.pdf