Dphhs-Qad/ccl-121 Medication Authorization Form
ADVERTISEMENT
1DPHHS-QAD/CCL-121
(Revision 10-06)
MEDICATION
AUTHORIZATION FORM
TO BE COMPLETED BY PARENT
Child’s Name__________________________________________________________Date of Birth_____/____/___
Program Name________________________________________________________Today’s Date_____/____/___
*************************************************************************************************
To administer a prescription medication:
•
The medication must be in it’s original container, with a legible label from the pharmacy indicating the child’s
name, date, name of medicine, dosage, and time, number of days medication is to be given, and expiration date of
medication, doctor’s/nurse practitioners name, pharmacy name and telephone number
•
Samples must be accompanied by a doctor’s written prescription
•
Medications are to be given only to the child indicated on the label (twins and siblings can not share.)
•
A separate authorization is required for each medication and each episode of illness
•
Label constitutes the physicians/nurse practitioner’s order
•
Parent/Guardian is to give as many doses as possible at home.
Medication:_______________________________________________________________________________________
Reason for medication:______________________________________________________________________________
Start date_____/____/___
End date____/____/____
Dosage:_______________
Times to be given at child care:________AM_______PM
First dose was given at_________AM/PM on date____/____/____ (Medication Log needs to reflect Parent’s first dose
for each day.)
Route: by mouth, skin (location)________, eye (R/L)
Possible side effects:_______________________________________________________________________________
Special handling/storage Instructions__________________________________________________Refrigeration Y/N
Parent/Guardian Signature (required)_______________________________________________________________
Physician/Nurse Practitioners Signature
_____________________________________________________________________
************************************************************************************************************
Non-Prescription Medication:
•
Parent is required to bring these medications from home.
•
Medication must be in an original container, with child’s name on the container.
Medication:__________________________________________Health Care Provider_____________________________
"For children under 2, list the name of the health care provider who recommended this
medication."
Reason for medication:_______________________________________________________________________________
Start date_____/____/___
End date____/____/____
Dosage:_______________
Times to be given at child care:________AM_______PM
First dose was given at_________AM/PM on date____/____/____ (Medication Log needs to reflect Parent’s first dose
for each day.)
Route: by mouth, skin (location)________, eye (R/L)
Possible side effects:________________________________________________________________________________
Special handling/storage Instructions____________________________________________________Refrigeration Y/N
Parent/Guardian Signature (required)__________________________________________________________________
____/____/____
Unused medication: Returned to Parent Y/N Date
or Discarded appropriately Y/N Method
By: ________________________________________________
Date _____/_______/_______
*Keep in the child’s file when medication is finished.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business