Preston County Schools
Standing Order Form
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Student’s Name
Grade/Teacher
Please indicate medications and dosages that may administered at school for the school year.
_____Tylenol/acetaminophen by mouth every 4 hours as needed for pain or fever:
___4-5yrs (36-47lbs) = 1½ tsp (240mg)
___6-8yrs (48-59lbs) = 2 tsp (320mg) or TWO “Meltaways” or ONE 325mg tablet
___9-10yrs (60-71lbs) = 2½ tsp (400mg) or TWO & HALF “Meltaways” or ONE 325mg tablet
___11 yrs (72-95lbs) = 3 tsp (480mg) or THREE “Meltaways” or ONE 325mg tablet
___12 yrs (96-100lbs) = 3½ tsp (560mg) or FOUR “Meltaways” or ONE 325mg tablet
___ >12 yrs = 4 tsp (650mg) or TWO 325mg tablets or ONE 500mg tablet
_____Motrin/ibuprofen by mouth every 6 hours as needed for pain or fever:
___4-5yrs (36-47lbs) = 1½ tsp (150mg)
___6-8yrs (48-59lbs) = 2 tsp (200mg) or ONE 200mg tablet
___9-10yrs (60-71lbs) = 2½ tsp (250mg) or ONE 200mg tablet
___11 yrs (72-95lbs) = 3 tsp (300mg) or ONE 200mg tablet
___12 yrs (96-100lbs) = 3½ tsp (350mg) or ONE 200mg tablet
___ >12 yrs = 4 tsp (400mg) or TWO 200mg tablets
_____Aleve/naproxen sodium: ONE tablet (220mg) by mouth every 8 hours as needed for pain
_____Tums or Rolaids: ONE tablet by mouth every 4 hours as needed for nausea, upset stomach or
stomach ache
_____Cough drop/throat lozenge: ONE by mouth every hour as needed for cough or sore throat
_____Benadryl/diphenhydramine by mouth every 6 hours as needed for itching/allergy symptoms:
___4-6 yrs = 1 tsp (12.5mg)
___6-12 yrs = 1-2 tsp (12.5mg-25mg)
___>12 yrs = 2-4 tsp (25mg-50mg)
_____Hydrocortisone cream 1%: Apply once a day for rash or itching
_____Calamine lotion: Apply once a day for rash or itching
_____Sting-eze: Apply after insect bite or bee sting
_____Antibiotic ointment: apply once a day to sores or wounds
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Signature of Licensed Provider (MD, OD, CNP, PA-C, etc.)
______________________________
Date
*Parent Reminder: Please send in the above marked medication for your child. These
medications can only be given using the medication provided by the parent/guardian.
Kingwood Elementary School – 207 S. Price St., Kingwood, WV 26537
Phone: (304) 329-1034 FAX: (304) 329-1035
Tammy Savage - School Nurse
www.kingwood.pres.k12.wv.us