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EMERGENCY USE OF AUTO-INJECTOR AUTHORIZATION <br />(Section 1) <br />(References: P.108.SCO and PR.548.SCO) <br />OCDSB 405 School Operations (June 2017) Confidential W hen Complete <br /> Page 1 of 2 <br />Distribution: OSR <br />Note: This page must be completed by the parent / guardian if the principal has determined <br />that it is necessary to equip the school with one or more non-prescribed Auto-Injectors, and <br />the parents/guardians are unable to provide the school with two Auto-Injectors. <br />School Name: Date: <br />Principal’s Name: Teacher’s Name: <br />ADVISEMENT OF ADMINISTRATION OF MEDICATION <br />Student’s Name: Student No. : <br />Parent/Guardian (if student is under 18 years of age): <br />Telephone (Home): Telephone (Business): <br />Address: <br />E-mail Address: <br />Physician’s Name: Physician’s Telephone: <br />PARENT/GUARDIAN AUTHORIZATION RE: ADMINISTRATION OF A NON-PRESCRIBED AUTO- <br />INJECTOR <br />I/we, the parent(s)/guardian(s) of <br />hereby give my consent to the Ottawa-Carleton District School Board (OCDSB), in the event of an <br />emergency and in the circumstances that a prescribed Auto-Injector is not readily available or not <br />provided to the school, to administer a non-prescribed epinephrine auto injector on my child, <br />which contains a dose of: <br />0.15mg of epinephrine <br />or <br />0.30mg of epinephrine <br />The responsibility for administration of medication involves certain elements of risk. Unexpected <br />consequences including, but not limited to, illness, adverse reactions or other complications may <br />occur as a result of the administration (or non-administration) of any medication. These physical <br />reactions result from the medication and can occur without fault on either the part of the student or <br />the Ottawa-Carleton District School Board (OCDSB) or its employees or agents. By requesting and <br />consenting to the administration of medication by the OCDSB to your child, you are assuming the risk <br />of an unexpected reaction occurring. It is understood that the chances of such a reaction occurring <br />may be reduced by carefully following the instructions provided by the physician and / or pharmacy at <br />all times. If you consent to the administration of medication to your child by the OCDSB, you must <br />understand that you and not the OCDSB will bear sole responsibility for any physical reaction that <br />might occur. <br />I have read the above and I understand that in requesting and consenting to the administration of <br />medication by the OCDSB, I am assuming the risks associated with doing so. <br />It is acknowledged that the employees or agents of the OCDSB are not medically trained to <br />administer medication. <br />Parent/Guardian Signature (or student if 18 years or older): <br />Date: