Health Service Forms

Medication Administration Information Form

• Parent/Guardian required to read, initial, and sign the form
• Only one form needed for all medications
• Form 1 of 2 

Medication Administration Information Form- Spanish Copy 

• El padre/tutor debe leer, rubricar y firmar el formulario
• Solo se necesita un formulario para todos los medicamentos.
• Formulario 1 de 2

Permission to Administer Medications at School

• Parent/ Guardian required to read, fill out, and sign the form 
• One form needed for each medication 
• Form 2 of 2 

Permission to Administer Medications at School- Spanish Copy 

• El padre/tutor debe leer, completar y firmar el formulario.
• Se necesita un formulario por cada medicamento.
• Formulario 2 de 2

Stock Emergency Medication Protocol

• Administration of Non-Student Specific Narcan - Only available at CMS & CHS 
• Administration of Non-Student Specific Epinephrine 
• Administration of Non-Student Specific Short-Acting Bronchodilator 

 

Other Health Forms: 

• Stock Medication - Parent/ Guardian Information and Consent Form_ Columbus School District 
• Asthma Action Plan _ Columbus School District 
• Allergy and Anaphylaxis Emergency Plan_ American Academy of Pediatrics 
• Concussion Sign and Symptoms Checklist_ CDC Heads Up 
• Diabetes Medical Management Plan_ American Diabetes Association 
• Diabetes (Type 1) Action Plan_ Columbus School District 
• Headache/ Migraine Action Plan_ Columbus School District 
• Medical Statement for Special Dietary Needs_ Wisconsin Department of Public Instruction
• Medical Statement for Special Dietary Needs_ Wisconsin Department of Public Instruction- Spanish
• Seizure Action Plan_ Epilepsy Foundation