MEDICATION ADMINISTERED
Except for the application of a nonprescription diaper rash treatment, sunscreen, or insect repellent
supplied by the child’s parent, each administration of a medication to the child shall be noted in the
child’s 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:
DATE
TIME
DOSAGE
REACTIONS OBSERVED (IF ANY)
SIGNATURE
OCC 1216 - Revised 12/11 - All previous editions are obsolete. Page 2 of 2