1. Name of Medication and/or Treatment
2. Purpose of Medication and/or Treatment
3. Time Intervals for Administration
4. Dosage and Procedure for Administration
5. Possible Side Effects
6. Procedure to Follow in Case of Adverse Reaction
7. Special Storage Instructions for the Medication
8. Security Requirements to Prevent Risk to Others
9. Termination Date for Administration
10. Authorization and Procedure for Student Self-Administration
11. Training Required
12. Medication to be Administered by:
| Signature of Parent/Legal Guardian | Date | |
| Signature of Doctor | Date | |
| Signature of Principal: | Date | |
| Signature of Individual Administering the Treatment/Medication: | Date |