ࡱ> tvqrs5@ bjbj22 "(XX 6666666J  4J     E E E UWWWWWW$RT{6E A E E E {66  ; E .6 6 U E U 66 0k& s 0r ^rJJ6666r6$E E E E E E E {{JJ . JJ.   ϳԹ Self-Medicating and/or Self-Monitoring Student  When completing this form, draw an X through any sections that do not apply. (Example: If you will not be self-monitoring, draw an X through the self-monitoring section.) ___________________________________________________________________________ Students Name________________ Date of Birth _________________________________________________________________ _______ Name of School Grade ________________ Homeroom Teacher List the medication(s) that you will be self-administering. List the monitoring device(s) that you will be using. Please read and initial each statement below if you agree. All are required in order to self-administer medications at school. I know when I should and when I should not take the medication(s) noted above. ________ I know the signs and symptoms that may mean that I should not take the medication(s). ________ I know how much of the medication(s) noted above I should take. ________ I know how to take the medication(s) noted above. ________ I will take the medication(s) the way that my health care provider has instructed. _______ I will keep the medication in the package provided by the pharmacy or my health care practitioner. ________ I will keep the medication and any supplies needed for taking the medication(s) with me in a safe place. ________ I will not allow other students to touch or hold my medication(s) nor any of the supplies needed for taking the medication. ________ I understand that I will no longer be able to take my medication on my own if I endanger myself or another student by misusing the medication(s). ________ I understand that I can only take the medication(s) noted above on my own. All other medications must be given to me by a school employee. ________ Please read and initial each statement below if you agree. All are required in order to self-monitor at school. I know when I should and when I should not use the monitoring device(s) noted above. ________ I know the signs that may mean that the monitoring device(s) is/are not working properly. ________ I know how often to use the monitoring device(s). ________ I will keep the monitoring device(s) and any supplies needed for using the monitoring device(s) with me in a safe place. ________ I will not allow other students to touch or hold my monitoring device(s) nor any of the supplies needed for using the monitoring device. ________ I understand that I will no longer be able to use the monitoring device(s) on my own if I endanger myself or another student by misusing the device(s). ________ I understand that I can only use the monitoring device(s) noted above on my own. All other devices must be used with the assistance of a school employee. ________  ____________________________________________________________________ ____________________ Students Signature Date ____________________________________________________________________ ____________________ Parents/Guardians Signature Date EFGHF U f t u v j {  B C $ % '(/0./EFʴʴʴʴʴʴʥʴʴʴʴʴʴʴʴʴʴʥʴʴʴʴʴʴʴʴʴh'C/5CJOJQJ^JaJh'C/CJOJQJ^JaJh'C/CJaJh'C/CJOJQJ^JaJh'C/OJQJh3OJQJh'C/CJOJQJaJjh3Uh'C/A=EFGHF U q|kd$$Ifl0?4)  t0644 la $$Ifa$$If U f t u v i j { Skd@$$Ifl0!4)o!1 t644 la$If   $IfSkd$$Ifl0!4)o!1 t644 la  B C $ % |||||||||||||$If|kd$$Ifl0d4) t0644 la '(/0./EF$If|kd$$IflS0d4) t0644 la h'C/CJOJQJ^JaJh'C/CJOJQJ^JaJ 1h/ =!8"#$%Dd3JP  3 ,A?RHS_1c_562_2R!dޚ$ D F!dޚ$ JFIF,,4ExifMM*bj(1r2i,,Adobe Photoshop CS Macintosh2008:03:13 11:30:38X&(.HHJFIFHH Adobe_CMAdobed            C" ?   3!1AQa"q2B#$Rb34rC%Scs5&DTdE£t6UeuF'Vfv7GWgw5!1AQaq"2B#R3$brCScs4%&5DTdEU6teuFVfv'7GWgw ?TU~?Nó7'wTn7s[}zH$I4[).w}>7e;]^%ϣeՍԳ歃<ƿ[F 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