Asthma Self Administration – Approved 2.23.2013


A Student may possess and use a metered dose inhaler or a dry powder inhaler to alleviate asthmatic symptoms, or before exercise to prevent the onset of asthmatic symptoms, of both of the following conditions are satisfied:

1. The Student has the written approval of the Student’s physician and, if the Student is a minor, the written approval of the Parent, guardian, or other person having care or charge of the Student.  The physician’s written approval shall include at least all of the following information.

  • the Student’s name and address;
  • the names and dose of the medication contained in the inhaler;
  • the date the administration of the medication is to begin;
  • the date, if known, that the administration of the medication is to cease;
  • written instructions that outline procedures School personnel should follow in the event that the asthma medication does not produce the expected relief from the Student’s asthma attack;
  • any severe adverse reactions that may occur to the Student using the inhaler and that should be reported to the physician;
  • any severe adverse reactions that may occur to another Student, for whom the inhaler is not prescribed, should such a Student receive a dose of the medication;
  • at least one (1) emergency telephone number for contacting the physician in an emergency;
  • at least one (1) emergency telephone number for contacting the Parent, guardian, or other person having care or charge of the Student in an emergency;
  • any other special instructions from the physician.

2. The Director and, if a School nurse is assigned to the Student’s School building, the School nurse has received copies of the written approvals required by Subparagraph 1 of this section.

If these conditions are satisfied, the Student may possess and use the inhaler at School or at any activity, event, or program sponsored by or in which the Student’s School is a participant.

The School, a member of the Board or the Board’s representatives, or any staff or employee is not liable in damages in a civil action for injury, death, or loss to person or property allegedly arising from a staff member’s prohibiting a Student from using an inhaler because of a staff member’s good faith belief that the conditions of Subparagraphs 1 and 2 of this Section had not been satisfied.  The School, a member of the Board, the Board’s representatives, or any staff or employee is not liable in damages in a civil action for injury, death, or loss to a person or property allegedly arising from a staff member’s permitting a Student to use an inhaler because of a staff member’s good faith belief that the conditions of Subparagraphs 1 and 2 of this Section had been satisfied, the School, any member of the Board, or the Board’s representatives, or any staff or employee is not liable in damages in a civil action for injury, death, or loss to a person or property allegedly arising from the use of the inhaler by a Student for whom it was not prescribed.

This Section does not eliminate, limit, or reduce any other immunity or defense that a School, member of a School Board (Governing Board, Governing Authority or Board of Directors), or staff or employee may be entitled to under Chapter 2744 or any other provision of the Revised Code or under the common law of this state.

INHALER PERMISSION FORM

All sections must be complete.  Completed form must be submitted to the Director and the School Nurse, if the School has one assigned.

**************TO BE COMPLETED BY THE PHYSICIAN**************

Student Name:  __________________________________

Student Address:  _________________________________

_________________________________

The above-named Student has the approval to possess and use the following inhaler medication to alleviate asthmatic symptoms.  Use must be according to the following specifications:

Name and dose of medication:  __________________________________________

Date the administration of the medication is to begin:  ________________________

Date, if known, administration of the medication is to cease:  ___________________

The following procedure is to be employed in the event that the medication does not produce the expected relief from an asthma attack:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________.

Please list any severe adverse reactions that may occur to the Student using the inhaler that should be reported to the physician:

_____________________________________________________________________________________________________________________________________.

Please list any severe adverse reactions that may occur to another student, for whom the inhaler is not prescribed, should such student receive a dose of the medication:

_____________________________________________________________________________________________________________________________________.

Any other special instructions:

_____________________________________________________________________________________________________________________________________.

Physician Signature ________________________________

Physician Name Printed _____________________________

Physician Address __________________________________

__________________________________

Emergency Telephone Number:  _______________________

*********TO BE COMPLETED BY A PARENT OR LEGAL GUARDIAN*********

Name an emergency number of a parent or guardian, or other person having care or charge of this Student in an emergency:

________________________________________________________________________

I, as the parent or legal guardian of the above-named student, do hereby give my approval for this Student’s possession and use of the inhaler medication described above.

Parent/Guardian Signature ______________________________

Parent/Guardian Name Printed ___________________________