_________________________________      ___/___/___   _________________  ___/___/___

Student's Name (Last), (First)  (Middle)            Birthday                  School                   Date

The following must occur for a student to self-administer asthma or other airway constricting disease medication or for a student with a risk of anaphylaxis to self-administer an epinephrine auto-injector:

• Parent/guardian provides signed, dated authorization for student medication self-administration.
• Parent/guardian provides a written statement from the student’s licensed health care professional (A person licensed under chapter 148 to practice medicine and surgery or osteopathic medicine and surgery, an advanced registered nurse practitioner licensed under chapter 152 or 152E and registered with the board of nursing, or a physician assistant licensed to practice under the supervision of a physician as authorized in chapters 147 and 148C) containing the following:
  • Name and purpose of the medication,
  • Prescribed dosage, and
  • Times or special circumstances under which the medication or epinephrine auto-injector 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 shall be renewed annually.  In addition, 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, the school shall permit the self-administration of medication by a student with asthma or other airway constricting disease or the use of an epinephrine auto-injector by a student with a risk of anaphylaxis 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 If the student abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

Pursuant to state law, the school district or and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication or use of an epinephrine auto-injector by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district is to incur no liability, except for gross negligence, as a result of self-administration of medication or an epinephrine  auto-injector by the student as provided by law.

 

                                                                                                                                               

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.

 

                                                                                                            /           /          

Parent/Guardian Signature                                                     Date

(agreed to above statement)                           

 

                                                                                                                                               

Parent/Guardian Address                                                       Home Phone

 

                                                                                                                                               

                                                                                                Business Phone

 

 

                                                                                                                                               

 

                                                                                                                                               

 

                                                                                                                                               

Self-Administration Authorization Additional Information              

Reviewed: 11/11/2024                               

 

_________________________________                 ___/___/___     _________________  ___/___/___

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

 

Reviewed: 11/11/2024

Reviewed:

11/11/2024

Regulation 507.08-R(1): Student Special Health Services - Regulation	Status: APPROVED
Original Adopted Date: 01/22/2020 | Last Revised Date: | Last Reviewed Date: 11/11/2024

 

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 health plan.

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 in accordance with licensed practice 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 in the student's education record.

"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 , or as described in the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act of 1973 .

"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, nursing diagnosis, outcomes, planning,interventions, evaluation, student goals, if applicable, and a plan for emergencies.  The plan is updated as needed and at least annually.  Licensed health personnel develop this written plan with collaboration from the parent or guardian, individual’s health care provider or 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 under the auspices of the school.

"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 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 parents 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 and qualifications of school personnel performing health services.
• Review of the designated person's competency.
• Determination of initial and ongoing level of supervision, monitoring and evaluation required to ensure quality services.

E. Licensed health personnel will supervise the special health services, define the level and frequency 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, written consent of personnel as required in Iowa Code 280.23 and periodic updates are on file at school.

G. Parents will provide the usual equipment, supplies and necessary maintenance for such, unless the school is required to provide the equipment, supplies, and maintenance under the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act of .1973.  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.
 

 

I.C. Iowa Code	Description
Iowa Code  § 256.11	DE - Educational Standards
Iowa Code  § 256B	Special Education
Iowa Code  § 273.2	AEA's Powers, Services, Programs
Iowa Code  § 273.5	AEA's -Special Education
Iowa Code  § 273.9	AEA's - Funding
Iowa Code  § 280.8	Uniform School Requirements - Special Education
I.A.C. Iowa Administrative Code	Description
281 I.A.C. 14	Special Health Services
U.S.C. - United States Code	Description
20 U.S.C. §§ 1400	IDEA - General Provisions
U.S. Supreme Court	Description
480 U.S. 279	School Board of Nassau Cnty. V Arline (1987)
Case Law	Description
Board of Education v. Rowley	458 U.S. 176 (1982)
SE Warren CSD  v. Dept. of Public Instruction	285 N.W.2d 173 (Iowa 1979)
Springdale SD #50 v. Grace	693 F.2d 41 (8th Cir. 1982)

Cross References

Code	Description
603.03	Special Education
711.01	Student School Transportation Eligibility

 

Specific Wellness Goals:

• Increase low fat/low sugar options on menus, ala carte and concession stands;
• Gather appropriate information from health and fitness professionals within the school district and surrounding community for development of appropriate fitness, weight management, and healthy eating programs for staff. 
• The nutrition guidelines for all foods available will focus on promoting student health and reducing childhood obesity in the school district.

 The school district will provide physical education that:

• is daily (The Centers for Disease Control and Prevention recommends at least 150 minutes a week for elementary students and 225 minutes a week for middle and high school students);
• 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.

Elementary schools should provide recess for students that:

• is at least 20 minutes a day;
• is preferably outdoors;
• encourages moderate to vigorous physical activity verbally and through the provision of space and equipment; and,
• 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.
• Employees should not use physical activity (e.g., running laps, pushups) or withhold opportunities for physical activity (e.g., recess, physical education) as punishment.

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 district level will ensure compliance with nutrition policies within food service areas and will report on this matter to the superintendent or principal.
• 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 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. 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 two 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.

REVIEW: 11/11/2024