STATE OF HAWAII
DEPARTMENT OF EDUCATION
REQUEST TO STORE AND ADMINISTER EMERGENCY RESCUE MEDICATIONS
AND DAILY, ROUTINE, SCHEDULED MEDICATIONS, AS APPLICABLE
AT
SCHOOL
FOR
-
SCHOOL YEAR
Please complete this form in ink.
STUDENT’S NAME (Last, First):
BIRTHDATE:
HOME ADDRESS:
HOME PHONE:
Parent 1/Legal Guardian’s Name:
Home Ph #:
Cell #:
Work #:
Parent 2/Legal Guardian’s Name:
Home Ph #:
Cell #:
Work #:
Legal Guardian’s Name
Home Ph #:
Cell #:
Work #:
Please check student’s health insurance plan: QUEST MEDICAID TRICARE HMSA-Private KAISER-Private
OTHER (specify):
NONE
I. PARENT’S / LEGAL GUARDIAN’S REQUEST, AUTHORIZATION, and WAIVER OF LIABILITY
Request and Authorization:
I, the undersigned, request and authorize the following individuals to administer medication to my child as
prescribed by my child's physician or other practitioner with prescribing authority in a medication order:
personnel of the Department of Education (DOE), personnel of the Department of Health (DOH), and nurses
assigned by the DOE pursuant to a written agreement.
I request and authorize the release of health information among the DOE, the DOH Public Health Nurse (PHN),
the prescribing physician or other practitioner with prescribing authority, and the dispensing pharmacist
pertinent to my child’s condition. I understand that I will be informed by the PHN, the prescribing physician or
other practitioner with prescribing authority if there are any changes to my child's medication order.
I have read the instructions on page 3 of this request form, “Notice to Parents/Legal Guardians
and Physicians.”
I will provide a recent photograph of my child.
I agree I am responsible to provide appropriately labeled medications in accordance with the
instructions on page 3 of this request form.
PARENT’S/LEGAL GUARDIAN’S SIGNATURE: _________________________________________________
PARENT’S/LEGAL GUARDIAN’S (Type/Print): __________________________________________________
DATE: __________________
Waiver of Liability:
NOTICE: The DOE, the DOH, and their employees and/or agents shall not incur any liability as a result of any
injury arising from the administration of the emergency rescue medications or daily, routine, scheduled
medications specified on this form.
My signature below indicates that:
I understand and I agree that the medication may be administered by a specifically trained non-health
care professional; and
I agree that the DOE and the DOH and their employees or agents, including nurses assigned by the
DOE pursuant to a written agreement, shall not incur any liability as a result of any injury arising from
the administration of the emergency rescue medications or daily, routine, scheduled medications
specified on this form.
PARENT’S/LEGAL GUARDIAN’S SIGNATURE: _________________________________________________
PARENT’S/LEGAL GUARDIAN’S (Type/Print):__________________________________________________
DATE: ___________________
SH36, Revised 2021 Page 1 of 3 (SEE PAGE 2)
Student’s Name: ___________________________________________________Birthdate:_______________________
II. PHYSICIAN’S or OTHER HEALTH PROFESSIONAL’S REQUEST
DIAGNOSIS: _______________________________________________________________________
WEIGHT: _________ ALLERGIES: _____________________________________________________
EMERGENCY RESCUE MEDICATIONS AND DAILY, ROUTINE, SCHEDULED MEDICATIONS:
EMERGENCY RESCUE MEDICATION
(Name/Dosage/Route)
TIME TO BE GIVEN
DESCRIPTION OF
OTHER
ADMNISTRATION
INFORMATION
Rescue Medications
EMERGENCY RESCUE MEDICATION --
Epinephrine:
□ Epinephrine auto-injector, Premeasured
dose of 0.15 mg, IM (33-66 lbs)
□ Epinephrine auto injector, Premeasured
dose of 0.3 mg, IM (>66 lbs)
EMERGENCY RESCUE MEDICATION --
Inhaler:
□ Inhaler (Name): _____________________
Dosage_____________/#puffs:___________
First
administration:
immediately upon
onset of life-
threatening
symptoms.
Second
administration:
Repeat dose in
___ minutes of first
administration.
Upon onset of
Asthma Symptoms.
Life threatening
SYMPTOMS:
Actions for
Epinephrine:
The school shall call
911 immediately after
first administration.
The school shall
notify the parent/legal
guardian after calling
911.
Action for Inhaler:
- If assigned nurse is
available, nurse can
assist, assess student
for decision on
disposition.
-
If no nurse is
available, call parent
to pick up student
after administration of
medication per SHA
Manual procedure.
Call 911 if indicated
in student’s
Emergency Action
Plan.
DAILY, ROUTINE, SCHEDULED MEDICATION
(Medication/Dose/Frequency/Route)
TIME(S) TO BE
GIVEN:
Reason(s) medication(s) need(s) to be given
during the school day:
The above indicated medication(s) is/are necessary for the health of the student and for the student’s attendance
at school and school related functions: □ Yes □ No
Physician’s (or other practitioner with prescriptive authority) Signature: ____________________________ DATE: ____________
Physician’s (or other practitioner with prescriptive authority) Name (type/print): ________________________________________
Telephone: ____________________ FAX: _____________________
Address: __________________________________________ City: _______________ Zip: _______________
SH36, Revised 2021 Page 2 of 3 (SEE PAGE 3)
Note: SH36 review and consultation has been completed by an agent of the DOH. Administration of medication
to the above named student as requested by the parent/legal guardian and prescribed by the physician
is approved by the DOH for administration in the school setting.
is not approved by the DOH for administration in the school setting.
DOH PHN’s initial: ______ Date: ________________________
Shortness of breath
Chest tightness
Wheezing
Frequent coughing
Other: (fill in)
Asthma SYMPTOMS:
(any one or more)
Hives, itching, and flushed or pale skin
Swelling of the face, eyes, lips, or throat
Wheezing and trouble breathing
Weak and rapid pulse
Nausea, vomiting, or diarrhea
Dizziness, fainting, or unconsciousness
Other (fill in):
(any one or more)
Albuterol (90 mcg/puff)
Levalbuterol (45 mcg/puff)
Use with valved-holding chamber
(will need to be prescribed one for school,
make sure prescribe with or without
facemask as appropriate)
(6 puffs can be used
for >/=5 year olds.
Do NOT prescribe a
range of puffs such
as 4 to 6)
Repeat dose in
15 minutes of
first administration
if continues to
have asthma
symptoms as
described in
next column
NOTICE TO PARENTS/LEGAL GUARDIANS AND PHYSICIANS
(Please keep this page for your future reference.)
Please note: School health assistants are unlicensed non-health professionals who are specifically
trained in medication administration. They are not able to perform clinical assessments
necessary to determine the need for medication or response to medication, but they are provided
with protocols to follow in situations where medication is needed.
1. Medications that are provided by the parent/legal guardians pursuant to this form, shall be stored in the
school health room. No other medications will be stored in school.
2. Medications should be given at home as much as possible unless the physician or other practitioner with
prescriptive authority provides reasons on this form why medications must be given during the school day or
at a beyond-the-school day event/program. In that event, emergency rescue medications and daily, routine,
scheduled medications shall be administered as prescribed and requested by this form.
3. Antibiotics, analgesics, and over-the-counter medications will not be stored or administered at school.
4. No “as needed” pro re nata (PRN) medications will be stored or administered during the school day because
school health aides administering medication are not able to perform clinical assessments necessary to
determine the need for medication.
5. Epi-Pen, Glucagon and inhalers, defined as emergency rescue medications, may be administered on an
emergency basis if they have been prescribed by a physician or other practitioner with prescriptive authority,
and the parent/legal guardian has requested their administration in accordance with this form, or with Hawaii
Revised Statutes (HRS) §302A-853.
Epi-Pen or Glucagon: When administered, the school will call 911 and notify the parent/legal guardian. The
school will defer to Emergency Medical Service (EMS) personnel with respect to whether transport to a
medical facility is needed. If EMS personnel determine that transport to a medical facility is not needed, the
parent/legal guardian will be informed to pick up the student.
Emergency inhalers: When administered by an unlicensed non-health professional, the school will notify the
parent/legal guardian to pick up the student. When administered by the assigned nurse, the nurse may
assess the student and determine whether to allow the student to remain in school or be sent home.
6. No medications will be administered by the authorized DOE or DOH personnel without the completion of this
SH36, Revised 2021, which includes the following requirements:
a. Parent/legal guardian must complete Section I, PARENT’S/LEGAL GUARDIAN'S REQUEST,
AUTHORIZATION, and WAIVER of LIABILITY;
b. Physician or other practitioner with prescriptive authority must complete Section II, Physician’s or
Other Health Professional's Request;
c. DOH must approve the form; and
d. The completed form must be submitted by the PHN to the School Health Aide at the school, and
maintained on file in the school health room.
7. In order for medications to be stored and administered in school, the medications must:
a. Be dispensed by a pharmacist in accordance with HRS §328-16 (a)(10);
b. Be in a container/vial labeled “FOR SCHOOL USE;”
c. Include the name of the student, name of the medication, dosage, strength, time of administration,
and name of prescribing physician or other practitioner with prescribing authority. The instructions
on the container must state, “FOR SCHOOL USE;” and
d. Be designated on a completed Form SH36.
8. Parent/legal guardian is responsible for providing an appropriately labeled supply of medications and a
recent photo of their child to the health room at school. This should be coordinated with the school health
aide, the child's teacher(s), and the school principal. Medications that are discontinued or unused must be
picked up by the parent/legal guardian.
9. Should there be any new medication order(s) by the physician or other practitioner with prescribing authority,
a new “Request to Store and Administer Emergency Rescue Medications and Daily, Routine, Scheduled
Medications, As Applicable” (SH36, Revised 2021) must be completed and submitted as specified in this
form. The form may be sent to school with the new container/vial of medication to reflect the new order(s)
using the process specified on this form. Prescription refills based on the prescription on file do not
require a new form.
10. If your child is off campus during the regular school day to participate in a DOE sponsored activity, prior
arrangements must be made between the parent/legal guardian and the school in order for your child to be
able to receive scheduled medications. Otherwise, your child will NOT be able to receive the scheduled
medication for the day.
11. This form is applicable only for the current school year and must be renewed yearly.
Parent/legal guardian are responsible for submitting requests for the following school year
SH36, Revised 2021 Page 3 of 3