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Forms for Health Services Authorizations

Administering Medication at School

  • If possible, medication should be given at home
  • If medications cannot be given at home, they will be administered in compliance with the Guidelines for Medication Administration in Kansas Schools and the Kansas Nurse Practice Act. 
  • All school-administered medications must have the appropriate authorization forms completed by guardians and/or medical providers before they can be administered to students. 
  • All USD 497 medication forms can be found below. 

Forms

Allergy Intake Form

Complete this form if your student has severe allergies that require emergency medication. 

Child Health Assessment Form

All students under the age of 9 must have a health assessment completed to enroll in any Kansas school. If needed, have your healthcare provider complete this form and return it to the school nurse. 

Diabetes Intake Form

Complete this form if your student has been diagnosed with diabetes. 

Gastrostomy Tube Intake Form

Complete this form if your student has a gastrostomy tube (G-tube). 

Physician's Order for Specialized Feedings

Have this form completed by your student's healthcare provider if your student needs a G-tube feeding at school.

Kansas Asthma Action Plan

Complete this form with your student's primary care provider if your student has been diagnosed with any form of asthma. 

Over-the-Counter Medication Administration Form

Complete this form if your student will need over-the-counter medication at school. Only 10 doses may be given then a physician's note will be required according to the Guidelines for Medication Administration in Kansas Schools. 

Prescription Medication Form

Complete this form if your student needs prescription medication administered at school.

Self Administration Medication Form

Complete this form if your student carries either over-the-counter or prescription medication and self-administers as needed. 

Seizure Intake Form

Complete this form if your student has had seizure activity in the past. 

Historial de alergias graves y formulario de admisión

Complete este formulario si su estudiante tiene alergias graves que requieren medicamentos de emergencia.

Plan de Auto-Administración de Medicinas (Self Admin Med Form)

Formulario de Administración de Medicamentos Recetados (Prescription Med Form)

Autorización para Médicinas Sin Prescripción-Confidencial (OTC Med Form)