ࡱ> 3729 bjbj@@ x*h*h & & 8$(<<<<<$!<<:<<<6 I$QXm0>">">">"& X ~: Ϻ Bucks School District Competency Check List for Student Self Administration of Asthma Emergency Medication Name_____________________ GR____ HR ___ Effective: 20__- 20__ Parent/guardian must supply physician orders and all necessary equipment and supplies. To carry and self administer, the student must be able to: (check all that apply) ____ 1. Respond to and visually recognize his/her name. ____ 2. Identify his/her medication. ____ 3. Recognize and verbalize the signs and symptoms of an asthma episode. ____ 4. Demonstrate the proper technique for self-administering his/her medication. ____ 5. Verbalize that he/she needs to report to the nurse immediately after using the asthma inhaler. ____ 6. At nurses discretion, sign his/her medication sheet to acknowledge having taken the medication. ____ 7. Demonstrate a cooperative and responsible behavior in all aspects of self-administration of medication. _____________________ _______ _________ Name of Medication Dosage Frequency The above named student has demonstrated the ability to self-administer the physician-prescribed asthma medication as indicated by the criteria listed above. ___________ _________________________________ Date Nurse Signature As the parent/guardian of above named student, I relieve and release the Ϻ Bucks School District and its employees of any liability and responsibility as a result of the benefits or consequences of the above-listed medication when it is physician-prescribed and parent/guardian-authorized. I further acknowledge and agree that the School District and its employees bear no responsibility for ensuring that the medication is taken. By executing this document, I am warranting and representing that the above-named student is capable of self-administering the medication. I am aware that any improper use or sharing of the above-named medication will result in the immediate confiscation of the medication and loss of the privilege of self-administration if this medication policy is violated. ___________ ____________________________ Date Parent/Guardian Signature I agree to be responsible for my asthma inhaler and follow the directions for its use as ordered by my physician, as well as the districts medication policy. I am aware that any abuse of this privilege will result in the confiscation of my inhaler. ___________ _____________________________ Date Students Signature     6K^lu 9 : ; W ò堑seTFh pCJOJQJ^JaJ h gh5qCJOJQJ^JaJhrshrs5OJQJ^JhLn5CJOJQJ^JaJhrshrs5OJQJ^JhD5CJOJQJ^JaJ#hrshrs5CJOJQJ^JaJ h4&56CJOJQJ^JaJ h Y56CJOJQJ^JaJ h&56CJOJQJ^JaJ&hrshrs56CJOJQJ^JaJ h ghrs69 : ; : ; b c gdrs &dPgdrsgdrsgd gW  : ; _ ~ b c   : < G H  ! 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('v:El gvD84&I1'e.)1g-3\$7x8Z=q>_D Y e[!^N'^ee^fGKg prszv,5q-Piq`#Ln}V& @''' @UnknownG.[x Times New Roman5Symbol3. .[x Arial7$BCambria9. . Segoe UIC.,.{$ Calibri Light7..{$ CalibriA$BCambria Math"hxGxGBVznzn!20 3Q@P $Pv2!xx֛ Central Bucks School DistrictMario L. CanalesREBSTOCK, LORI Oh+'0 ( H T ` lx Ϻ Bucks School DistrictMario L. CanalesNormalREBSTOCK, LORI2Microsoft Office Word@@\?j@8$@8$zn ՜.+,D՜.+,L hp  Gateway  Ϻ Bucks School District Title XJRf~  Category7display_urn:schemas-microsoft-com:office:office#Editor xd_SignatureOrder TemplateUrl xd_ProgID7display_urn:schemas-microsoft-com:office:office#Author ContentTypeId CompetencyRADICE, DONNA8000.00000000000CANALES, MARYANNE,0x01010091EA14EB2EAE60448577596A4AA531FA  !#$%&'()+,-./01456R:;<=>?@ABCDEFGHIJKLMNOPQSTURoot Entry F I$8 1Table>"WordDocumentxSummaryInformation("DocumentSummaryInformation8*MsoDataStore r I$6 I$HIZVYKMHGVNN2S==2r I$ I$Item PropertiesSU0LHFUD4JJGM==2 r I$ I$Item  950Properties}S5WBF5YMQIQ==2 r I$6 I$Item PropertiesOCompObj$r  !"#% This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q