Request For Administration Of Medication - Ohio Department Of Job And Family Services Page 2
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2Box 3 - The section below must be completed by the center or type A home staff and each administration of
medication must be documented. All dosages must be recorded on page 2 of this form.
_______________________________ was given ____________________ in the amount of _______________
(Name of Child)
(Name of Medication,
(Dosage)
Vitamin or Diet)
Date and Time of Dosage
Dosage Amount
Signature of Designated Person Administering Medication
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)
Page 2 of 2
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