Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Wappingers Junior High School 4 OVER-THE-COUNTER (OTC) MEDICATION AUTHORIZATION Student Name: ___________________________________________________ If your child uses an OTC not listed below, have the doctor list the OTC and approve it in the space provided. Dosage and frequency must be written out. Instructions on a medication’s bottle or box are not acceptable. Drug Name Dosage Requires Refrigeration (Yes/No) Frequency Possible Side Effects Indications Health Provider Order Tylenol/generic Pain or fever Yes No Advil/Ibuprofen Pain or fever Yes No Robitussin/generic Yes No Pepto-Bismol Cough Upset stomach, diarrhea Yes No Mylanta Upset stomach Yes No NyQuil Flu symptoms Yes No DayQuil Flu symptoms Yes No Sudafed Nasal congestion Yes No Dramamine Yes No Dimetapp Motion sickness Nasal congestion, allergy Yes No Benadryl Allergic reactions Yes No Hydrocortisone cream Allergic reactions Yes No Allergic reactions Yes No Yes No Yes No Yes No Yes No Yes No Yes No Calamine lotion Other OTCs a) b) c) d) e) f) I authorize a designated Wappingers Junior High School staff member during the 7th grade trip to Boston to oversee the administration of the medication listed above by my self-directed child. I hereby release the designated school personnel and the Board of Education of any liability relative to the administration and/or reaction of the medication on the above-named student. Parent/Guardian signature ____________________________________ I authorize WCSD school personnel to oversee the administration of the medication listed above by my selfdirected patient. Physician’s signature: _____________________________________ Phone #: ______________________