ACETAMINOPHEN

Plymouth Public Schools

Parent/Guardian Consent for Medication Administration

(Page 1 of 2)
Student: _______________________________________
Male

Female

Date of Birth: ______________ Grade: ____________ Date of Consent: __________

My son/daughter is known to have the following allergies:

Diagnosis (if not in violation of confidentiality):

______________________________________________________________________
1. I request and give permission to the school nurse to give my son/daughter:
Medication: Acetaminophen

Dosage: ___________________

Route:

Time of Day:

Oral

Prescribed by:
2. I give permission to the school nurse to share with appropriate school personnel
information relative to the prescribed medicine administration as s/he determines
necessary for my childs health and safety.

Yes

No
3. I understand that in the event of a field trip, this medication administration plan may
need to be adjusted and I will do the following:

Call the school nurse prior to the field trip to discuss the plan for
administering this medication

This medication may be withheld (not given) on the day of the field trip.
4. I understand that I may retrieve the medicine from the school at any time, and that
the medicine will be destroyed if it is not picked up within one week following the
termination of the order or the last day of school.
Parent/Guardian Signature: ___________________________ Date: _____________

ACETAMINOPHEN
Student Name:

Plymouth Public Schools

Parent/Guardian Consent for Medication Administration

(Page 2 of 2)
MEDICATION ADMINISTRATION PLAN (To be completed by the School Nurse)
Medication: ACETAMINOIPHEN (Tylenol, Apra, Apap, Asprin Free) Duration of Medication:
Date Ordered:

Expiration Date of Medication:

Time to be Given:

Quantity Received:

Contraindications/Side Effects: Hypersensitivity to drugs. Use cautiously in patients with any type of
liver disease, and in patients with long term alcohol use since therapeutic doses cause hepatotoxicity in these
patients. / Stage I (up to 24 hours) can cause abdominal pain, diaphoresis, nausea, vomiting, malaise, pallor.
Stage II (24-36 hours) RUQ pain, elevated liver functions and PT. State III (72-96 hours) hepatic failure,
encephalopathy, coma. In children, do not exceed five (5) doses in 24 hours. May decrease glucose,
hematocrit and hemoglobin levels. May falsely decrease glucose levels in home monitoring systems. Can
cause jaundice, rash, urticaria leukopenia, neutropenia, pancytopenia, electrolyte disturbance, dehydration,
tinnitus, vertigo, confusion, drowsiness diarrhea. Should not be given to children recovering from chicken pox
or flu-like symptoms due to risk of Reye syndrome.

Onset/Peak/Duration:

O: 1 hour

P 2-3 hours

Refrigeration:

Yes

 No

IHCP Indicated:

Yes

No

Original MD order received:

Yes

No

Entered into Health Office Computerized Database :

D: 8-12 hours

Medication Administration record completed and placed in medication book:

School Nurse Signature: _________________________________Date:

Medication may be given 30 minutes before or after scheduled time; or at an alternate time if
school schedule or activities change.
Parent form med consent_Acetaminophen.doc
Created July 12, 2011