Medication Administration Authorization Page 2

MEDICATION ADMINISTERED

Each administration of a medication to the child shall be noted in the child’s record. Each administration of prescription or non-

prescription to a child, including self-administration of a medication by a child, shall be noted in the child’s record. Basic care items such as: a

diaper rash product, sunscreen, or insect repellent, authorized and supplied by the child’s parent, may be applied without prior approval of a

licensed health practitioner. These products are not required to be recorded on this form, but should be maintained as a part of the child’s

overall record. Keep this form in the child’s permanent record while the child remains in the care of this provider or facility.

Child’s Name:

Date of Birth:

Medication Name:

Dosage:

Route:

Time(s) to administer:

DATE

TIME

DOSAGE

REACTIONS OBSERVED (IF ANY)

SIGNATURE

OCC 1216 (Revised 08/20/15) – All previous editions are obsolete.)

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Parent category: Medical