Request For Administration Of Medication - Ohio Department Of Job And Family Services

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Ohio Department of Job and Family Services
Child Care Centers and Type A Homes
This form is valid for no longer than twelve (12) months. One form must be used for each medication.
Box 1 - The following section must always be completed by the parent/guardian.
Check all that apply:
Prescription medication
Topical product or lotion
Nonprescription medication
Food supplement
Refrigeration required
Modified diet
Complete all of the following information:
Name of child:___________________________________ Date of birth: _______________Weight: __________
Name of medication:______________________________ Exact dosage: _______________________________
To be administered at the following times_________________________________________________________
For the following period of time:________________________________________________________________
Parent/Guardian signature:________________________________________________ Date: _______________
Box 2 -The following section must be completed by a licensed physician, a licensed dentist or an advance
practice nurse when:
1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or
underweight per the label instructions); or
2. It is a sample medication without a prescription label; or
3. The nonprescription medication is to be given longer than three consecutive days within a fourteen day
period or is a topical product or lotion that is being used for a skin ailment and is to be applied longer than
fourteen consecutive days; or
4. The child is on a modified diet (an entire food group is eliminated) or food supplement; or
5. The medication contains codeine or aspirin.
_________________________________ is under my care and should receive _____________________________
(name of child)
(name of medication, vitamin, diet)
as follows: ___________________________________________________________________________________
(include dosage and instructions)
Possible side effects to watch for are: ______________________________________________________________
Expiration date: _______________ (May not exceed 12 months from the date of this request for medications or food
______________________________________________ _________________ ___________________________
Signature of physician, dentist or advance practice nurse
Date of signature
Phone number
This form must be used by child care centers and type A homes to meet the requirement of OAC rules 5101:2-12-31 and 5101:2-13-31
JFS 01217 (Rev. 9/2005)
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