Medical Forms
Medical Forms in Jeffco
Families must complete the required forms and have them signed by their healthcare provider if their student has a condition that requires the administration of any medication during the school day.
To fill out any of the forms below:
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Click on the form link.
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Download the form.
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Print the form.
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Fill out the form.
Medication Forms
Families must provide a Medication Agreement form, completed and signed by their healthcare provider if their student has a condition that requires the administration of any medication during the school day. This includes over-the-counter and prescription medications.
Families will provide medication in the original packaged or prescription container that has not expired with the signed medication form below. Once received, a nurse may delegate administration of a prescription or over-the-counter medication, based on the health care provider's order.
According to Board policy JLC and Colorado Nursing Board Policy #30-04, district nurses must call physicians to verify orders if needed.
Medication agreement form
Medication Agreement (English) Acuerdo de medicación (Spanish) Разрешение на выдачу лекарств (Russian)
Extended field trip medication forms
One of the following forms must be completed for any overnight field trip.
CO State Asthma Care Plan
Students who require an inhaler or medication for asthma need their healthcare provider and families to complete the Colorado Asthma Care Plan and return it to the school health aide with the medication.
This form replaces the medication agreement form. Families of students with asthma or health concerns are encouraged to contact their District Registered Nurse (RN) to follow up regarding care and support at school.
CO State Allergy Care Plan
Many students have potentially life-threatening food allergies. To address this issue and meet state law requirements concerning managing food allergies and anaphylaxis among students, the Board has established Policy JLCDA. This policy specifies details about a health care plan, reasonable accommodations, access to emergency medications and staff training.
Families, the school administrator, and the District RN will develop a health plan using the Colorado Allergy and Anaphylaxis Care Plan, which you can have your care provider complete and return to the school. This form replaces the above medication agreement form.
CO State Seizure Care Plan
In 2021, the Colorado General Assembly passed HB-21-113 to prioritize school safety for students who have a seizure disorder, including epilepsy. This bill addresses strategic resources for kindergarten through 12th-grade schools to provide a safer environment for these students, including school personnel training, individualized seizure action plans and seizure care guidelines.
Your District RN will work with you to develop a health plan using the Colorado Seizure Care Plan which you can have your provider complete and return to the school. This form replaces the above medication agreement form.
Medication Guidelines for Parents
Jeffco families must submit a medical provider-signed agreement if their student requires medication during the school day.
To ensure the health and safety of all Jeffco students, these strict guidelines must be followed:
- All medications must be administered at school by Dennison staff.
- Medications must be accompanied by a completed medical provider-signed agreement form.
- Medications must be in original packaging
- Medications in Ziploc bags are not accepted and wil not be administered.
- Medications must be current.
- No expired medications can be accepted or will be administered.
- Packaging must indicate the expiration date.
- The medication dose must match the doctor’s prescription for the medication.
- For example: If a physician orders 160 mg of Tylenol, 500 mg tablets will not be accepted or administered.
- Medication tablets cannot be split at school.
- For example: If a physician orders 240 mg of Tylenol chewables – one and a half tablets–then parents must split some of the tablets and send them to school.
- These split tablets can be in a Ziploc bag inserted into the original Tylenol box.
- The medication product type must match the doctor’s order for the medication.
- For example: If the doctor orders liquid Tylenol, the parent must provide liquid Tylenol.
- We cannot accept Tylenol tablets or chewables.
- Generic and store brands are accepted.
- For example: If a physician orders Tylenol, acetaminophen is accepted.