HEAD START MEDICATION ADMINISTRATION

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1 HEAD START MEDICATION ADMINISTRATION Dear Parents/Guardians: It is the policy of Head Start to cooperate with each Head Start child's parent/guardian and his/her physician by administering and providing a safe place for the storage of medication deemed necessary by the child's physician. If your child needs to take medication of any kind at school, the following will be needed to ensure that it is given safely and properly: 1) A completed Medication - Physician/Parent Release form (copy attached). All information on Parent Request and Physician Instructions must be completely filled in. 2) The medication itself in the original prescription container must be brought to school by the parent/guardian or an adult designated by the parent/guardian. The pharmacy will provide a second prescription bottle for school use upon request. A separate form must be completed for each medication if more than one medication is given. A new Medication - Physician/Parent Release form must be completed annually or whenever there is any change in the medication dosage, form, time to be given, etc. Medication - Physician/Parent Release forms are available at your child s Head Start center. You may want to keep a copy with you so that you will always have one available whenever your child s doctor prescribes medication that needs to be taken during school hours. If you have any questions, please contact your Head Start representative. Thank you for your cooperation.

2 SETA OPERATED PROGRAM HEAD START MEDICATION - PARENT/PHYSICIAN RELEASE POLICY GOVERNING THE ADMINISTRATION OF MEDICATION BY HEAD START PERSONNEL Consistent with federal Head Start regulations regarding the administration, handling, and storage of medication for Head Start children, it is the policy of the SETA Operated Program to cooperate with each Head Start child's parent/guardian and his/her physician by administering and providing a safe place for the storage of medication deemed necessary by the child's physician. Selected Head Start personnel may store and/or dispense such medication to a Head Start child upon written request of the child's parent/guardian and physician only when the medication is in the original container. Medication will be administered only when designated SETA Head Start personnel are provided with a completed and signed original SETA HEAD START MEDICATION - PARENT/PHYSICIAN RELEASE, the purpose of which is to provide to SETA staff: (1) a written statement from such physician detailing the method, amount, and time schedules by which such medication is to be taken, and (2) a written statement from the parent or guardian of the child indicating the desire that the SETA Operated Program assist the child in the matters set forth in the physician's statement. PARENT REQUEST Child's Name Center Birthdate My child will need to take (Name of Medication) during Head Start. I, the undersigned, parent/guardian of (Child's Name) request that medicine be administered to said child by a member of the center staff, in accordance with instructions outlined on the reverse side of this release and signed by our physician. In agreeing to have center staff administer our child's medication, I voluntarily agree to release, discharge, and hold harmless Head Start and its employees from any and all claims of liability arising out of their negligence, recklessness or any other act or omission which causes our child's illness, injury, death, and/or damages of any nature in any way connected with the administration of our child's medication. I understand that the major responsibility for a child taking medication rests with his/her parent/guardian, and that I am required to personally bring the medication to school. Parent/Guardian Signature: Date: Address: Home Phone: Emergency Contact: Work/Cell Phone: Phone:

3 PHYSICIAN INSTRUCTIONS FOR MEDICATION ADMINISTRATION PLEASE NOTE: Medical personnel are not available at the Head Start Center. Whenever possible, please prescribe medication that can be given outside of the school day. If medication must be administered during school hours, please complete the information below: Child s Name: Birth Date: Medication(s): NAME DOSAGE ROUTE LENGTH OF TIME Special instructions/precautions: Possible side effects: Physician's Name: (Please Print) Physician's Signature: Date: Address: Phone:

4 ADMINISTRACION DE MEDICINAS EN HEAD START Estimados padres de familia o tutores: Es la norma de Head Start el cooperar con los padres o tutores y el médico de cada uno de los niños de Head Start para administrar y proporcionar un lugar seguro para el almacenamiento de las medicinas que el doctor del niño considere necesarias. Si el niño necesita tomar algún tipo de medicamento durante las horas de escuela, necesitará lo siguiente para asegurar que la medicina se administre de una manera segura y adecuada: 1) El formulario Medicinas del doctor y autorización del padre (adjunto) lleno. Toda la información en las partes de Petición del padre o tutor e Instrucciones del doctor llenas. 2) Las medicinas deberán estar en su envase original y entregado a la escuela por el padre o tutor, o una persona designada por el padre o tutor. Si lo pide, la farmacia le proporcionará un segundo envase para que lleve la medicina a la escuela. Debe llenar una forma por cada medicina que se le tenga que administrar al niño. Un nuevo formulario de Medicinas del doctor y autorización del padre deberá ser entregado a la escuela cada año o siempre que haya un cambio en la dosis de la medicina, método, horario, etc. El formulario de Medicinas del doctor y autorización del padre está disponible en el plantel de Head Start de su niño(a). Puede llevar un formulario extra para que siempre tenga uno disponible cuando el doctor del niño le recete medicinas que se tienen que tomar durante las horas de escuela. Si tiene preguntas, favor de comunicarse con su representante de Head Start. Gracias por su cooperación.

5 PROGRAMA HEAD START OPERADO POR SETA MEDICINAS DEL DOCTOR Y AUTORIZACION DEL PADRE NORMA QUE GOBIERNA LA ADMINISTRACION DE MEDICINAS POR EL PERSONAL DE HEAD START Conforme al reglamento federal de Head Start relacionado a la administración, manejo y almacenamiento de medicinas para los niños de Head Start, es la norma del programa operado por SETA el cooperar con los padres o tutores así como con los médicos de los niños para administrar y proporcionar un lugar seguro para el almacenamiento del medicamento que el doctor del niño considera necesario. El personal seleccionado de Head Start puede almacenar y administrar dicha medicina al niño de Head Start por medio de la petición escrita del padre o tutor y el doctor del niño solamente cuando el medicamento se encuentre en su envase original. MEDICINA DEL DOCTOR Y AUTORIZACION DEL PADRE PARA SETA HEAD START, el propósito del cual es proporcionar al personal de SETA: (1) una declaración escrita del doctor detallando el método, cantidad y horario para administrar dichas medicinas, y (2) una declaración escrita del padre o tutor del niño indicando el deseo para que el programa operado por SETA asista al niño en los asuntos presentados en la declaración del médico. PETICION DE LOS PADRES Nombre del niño(a) Centro Fecha de nacimiento Mi niño necesitará tomar durante Head Start. (Nombre de la medicina) Yo, el suscrito, padre o tutor de (Nombre del niño) pido que el medicamento sea administrado al niño(a) por un miembro del personal del centro, de acuerdo a las instrucciones indicadas al reverso de esta autorización firmada por el doctor. Al estar de acuerdo en que un empleado del lugar administre la medicina a mi niño(a), voluntariamente estoy de acuerdo en librar de cualquier cargo o culpa a Head Start y sus empleados de todo reclamo de responsabilidad que resulte de la negligencia, imprudencia o cualquier otro acto u omisión que cause enfermedad, lesión, muerte o daños de cualquier naturaleza a mi niño(a) y que de alguna forma esté vinculado con la administración de la medicina. Entiendo que la responsabilidad principal de que mi niño tome su medicina recae en el padre o tutor y que se requiere que yo personalmente traiga la medicina a la escuela. Firma del padre o tutor: Fecha: Dirección: Teléfono de la casa: Teléfono del trabajo o celular: Contacto para emergencias (nombre): Teléfono:

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