Wisconsin Department of Public Instruction H1N1 Information

Tdap/Varicella Vaccines

(Please print or type)

Date order effective to:___________________________________

School:_______________________________________________

Name of student:_______________________________________

Physician/Provider:_____________________________________

Diagnosis:____________________________________________

____________________________________________________.

Medication/dose/frequency/duration:_______________________

Medication/dose/frequency/duration:_______________________

Check one: Short term [ ] Long term [ ]

PRN (as situation demands) Medication:___________________________________________

Medication/dose/frequency/duration:_______________________

If PRN medication, state condition which medication is to be given:_______________________________________________

____________________________________________________.

NOTE

My signature on this document attests to my willingness and intent to direct and supervise the administration of the medication by non medically trained designees appointed by the school administration for that purpose. I will accept direct communications from them regarding the administration of the medication. This consent is valid for the current school year.

________________________________ ___________________

Physician signature                                  Date

My signature on this document confirms these medications have been prescribed for my child. I agree to this plan and will supply medications to the school in the pharmacy labeled bottle.

________________________________ ___________________

Parent signature                                     Date