Parent/guardian Authorization For The Administration Of Non-Prescription Topical Medications By Child Care Personnel Page 2
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1
2Medication Administration Record (MAR)
Name of Child ___________________________________________ Date of Birth ______/______/______
Pharmacy Name _________________________________________ Prescription Number _______________
Medication Order__________________________________________________________________________
Signature of
Date
Time
Remarks
Was This
Person
Dosage
Medication Self
Observing or
Administered?
Administering
Medication
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
*Medication authorization form must be used as either a two-sided document or attached first and second page.
Authorization form is complete
Medication is appropriately labeled
Medication is in original container
Date on label is current
Person Accepting Medication (print name)________________________________ Date _____/_____/_____
S:\Division\Licensure\Group&Ctr\FieldForms\Authorization-AdminMeds-NonTopical&MAR.doc 4/2/09
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