SAMUEL MICKLE SCHOOL NURSE
  • Welcome
  • Diabetes Education
  • Medication Administration Forms, Emergency Action Plan Forms & Guidelines
  • When to Stay Home
  • Health Screenings
  • Immunizations
  • Mental Health Awareness
  • COVID-19 UPDATES
  • Links/Resources
  • About Me

Medication Administation Guidelines & Forms
​Emergency Action Plan Forms 

General Medication Guidelines
The General Medication Dispensing Form is required for all prescription medications ordered for school,
as well as over-the-counter medications not covered under our standing order set.
General Medication Dispensing Form
Required for all students, except those with Asthma and Anaphylasis, who have medications or supplements prescribed as self-administration. 
General medication self-administration
The Asthma Action Plan (AAP) is the only form required for students diagnosed with asthma.
​A student may carry and self-administer the inhaler ONLY if the box is checked on the order form and
The Authorization for self-administration of medication & Waiver and Indemnification from Liability Form is compelted.
Asthma Action Plan
Authorization for self-administration of medication & Waiver and Indemnification from Liability Form
The Food Allergy & Anaphylaxis Emergency Care Plan (FARE) is required for all students that have an allergy requiring medication. 
The Authorization for self-administration of medication & Waiver and Indemnification from Liability Form is must also be completed.
Food Allergy & Anaphylaxis Emergency Care Plan
Indemnification Form for Epinephrine
 Required for all students with a diagnosis of migraines and currently being treated by a provider for headaches/migraines
Pediatric Migraine Action Plan (PedMAP)
The Seizure Action Plan is required for all students with a Seizure Disorder.  We also suggest completing the Quick Reference Form which will be used by teachers and staff.
Seizure Action Plan
Seizure Plan Quick Reference
The DMMP and Release of Information are required for all students diagnosed with Diabetes. The Authorization for self-administration of medication & Waiver and Indemnification from Liability Form  needs to be compelted if the student is permitted to self-administer their medication.
Diabetes Medical Management Plan (DMMP)
Authorization of Services & Release of Information
​A physical is ​ required for all students transferring into our district from out of state or out-of-country.  A completed copy along with the medical provider's stamp and date needs to be sent into school within 30 days of registration. The physical needs to have been completed within the last 365 days from the date of transfer. We will accept the prodiver's physical as long as it includes the PMH, Allergies, ROS, Medications and Screenings.
Physical Form

In Order to keep our information up-to-date, please forward any physicals compelted during the school year to the health office. The New Jersey Dept. of Health (N.J.A.C. 6A:16-2.2) recommends the importance of obtaining a physical examination of your child at least once during each developmental stage:
  • at early childhood (preschool through grade three) 
  • pre-adolescence (grade four through six) 
  • adolescence (grade seven through 12)
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  • Welcome
  • Diabetes Education
  • Medication Administration Forms, Emergency Action Plan Forms & Guidelines
  • When to Stay Home
  • Health Screenings
  • Immunizations
  • Mental Health Awareness
  • COVID-19 UPDATES
  • Links/Resources
  • About Me