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MEDICATION AUTHORITY FORM For students requiring medication to be administered at school |
The Medical Authority form should, ideally, be signed by the student’s medical/health practitioner for all medication to be administered at school but schools may proceed on the signed authority of parents in the absence of a signature from a medical practitioner.
- For students with asthma, Asthma Australia’s School Asthma Care Plan
- For students with anaphylaxis, an ASCIA Action Plan for Anaphylaxis
Please only complete the sections below that are relevant to the student’s health support needs. If additional advice is required, please attach it to this form.
Please note wherever possible, medication should be scheduled outside school hours, eg medication required three times daily is generally not required during a school day – it can be taken before and after school and before bed.
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Student Details |
Name of school: ________________________________________________________________________
Name of student:______________________________________Date of Birth: __________________
MedicAlert Number (if relevant): ______________________________________________________
Review date for this form:_____________________
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Medication to be administered at school: |
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Name of Medication |
Dosage (amount) |
Time/s to be taken |
How is it to be taken? (eg oral/topical/injection) |
Dates to be administered |
Supervision required |
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Start: / / End: / / OR □Ongoing medication |
□ No – student self- managing □ Yes □ remind □ observe □ assist □ administer |
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Start: / / End: / / OR □Ongoing medication |
□ No – student self- managing □ Yes □ remind □ observe □ assist □ administer |
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Medication delivered to the school |
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Please indicate if there are any specific storage instructions for any medication:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Medication delivered to the school |
Please ensure that medication delivered to the school:
□ Is in its original package
□ The pharmacy label matches the information included in this form
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Supervision required |
Students in the early years will generally need supervision of their medication and other aspects of health care management. In line with their age and stage of development and capabilities, older students can take responsibility for their own health care. Self-management should be agreed to by the student and their parents/carers, the school and the student’s medical/health practitioner.
Please describe what supervision or assistance is required by the student when taking medication at school (e.g. remind, observe, assist or administer):
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Monitoring effects of medication |
Please note: School staff do not monitor the effects of medication and will seek emergency medical assistance if concerned about a student’s behaviour following medication.
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Privacy Statement |
We collect personal and health information to plan for and support the health care needs of our students. Information collected will be used and disclosed in accordance with the Department of Education and Training’s privacy policy which applies to all government schools (available at:
http://www.education.vic.gov.au/Pages/schoolsprivacypolicy.aspx) and the law.
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Authorisation to administer medication in accordance with this form: |
Name of parent/carer: _________________________________________
Signature: _____________________________________________Date: _______________________
Name of medical/health practitioner:_________________________________________________________________
Professional role:_________________________________________________________________________________
Signature:_______________________________________________Date:______________________
Contact details:_____________________________________________________________________