IMPORTANT INFORMATION FOR PARENTS/GUARDIANS:
Your written consent is required before your student may receive these medications at school. Please complete the entire
form. By signing below, you acknowledge the following:
• Youhavereviewedtheinformationandagreethatyourstudentmaysafelytakethemedicationsaccording to the
recommended dose by weight.
• Theschoolnursehastheresponsibilityofapprovingyourstudent’suseofthesemedications.Inthecaseofastudent
with special health care needs, the school nurse may request authorization from your physician.
• Alicensedprescriber’sauthorizationwillberequiredif:
- Your student requires more than 2 doses in a single week.
- Your student requires more than 5 doses of acetaminophen and/or ibuprofen in a 30 day period;
- In the judgement of the school nurse, your student is ill and not improving.
• Yourstudent’smedicationmaybeprovidedbyanurse,anunlicensedhealthtechnician,orotherschoolpersonnel,
determined competent to provide medication as required by Nebraska law.
• Thesemedicationsareprovidedforuseduringschoolhoursand willbelimitedtoone doseperday.Purposeof
medicationistobenetlearningandattendance.
PARENTAL CONSENT FOR ACETAMINOPHEN AND/OR IBUPROFEN:
Igivepermissionfor:
Toreceivethefollowingmedication:Acetaminophen (Tylenol) q Yes q No | Ibuprofen (Advil) q Yes q No
Hasyourstudentexperiencednegativesideeectsfromacetaminophen:q Yes q No
Ifyes,explain:
Hasyourstudentexperiencednegativesideeectsfromibuprofen:q Yes q No
Ifyes,explain:
Please notify me BEFORE my student takes medications: q Yes q No
Please notify me the day my student takes medication: q Yes q No
Contact Name: Phone:
Please contact the School Nurse if your student has Special instructions concerning administration of
AcetaminophenorIbuprofen.
Signature of Parent/Guardian: Date:
Student Name
REQUEST TO PROVIDE MEDICATION DURING SCHOOL HOURS:
ACETAMINOPHEN AND IBUPROFEN
Health Services Department
Lincoln Public Schools • Lincoln, Nebraska
HS0059
Rev. 3/23