Medication Administration Form - California Childcare Health Program

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Health & Safety Form
Medication Administration Form
The (name of facility/center): ____________________________________________________ will administer medication to
children for whom a plan has been made and approved by the Director. Because medication poses an extra burden on
staff and having medication in the facility is a safety hazard, parents/guardians should check with the child’s health
care provider to see if a dose schedule can be arranged that does not involve the hours the child is in care by this facil-
ity/center. Parents/guardians may come to administer medication to their own child during the day.
If a liquid oral medication is to be administered at the facility/center, the parent/guardian must provide the admin-
istration device with clearly marked measurements (medicine sip-vial, medicine cup, dropper, or syringe).
Medication in Child Care:
1. Requires parent/guardian to complete and sign this Medication Administration Form; form shall be kept in the
child’s record with all supportive documentation.
2. Medication must be in original, child-proof container and labeled with child’s name.
3. All medication containers and dispensers will be stored out of the reach of children and in a locked cabinet, or
refrigerator if necessary, and will be returned to parent/guardian when completed.
4. Requires a written plan to record the administration of all medications and to inform the child’s parent/guardian
daily when such medications have been given.
5. When no longer needed by the child, or when the child withdraws from the program, all medications should be
returned to the child’s parent/guardian or disposed of after an attempt to reach parent/guardian.
Prescription Medications:
• Medication is administered in accordance with the pharmacy label directions as prescribed by the child’s
health care provider.
• The instructions from the child’s parent/guardian shall not conflict with the label directions as prescribed by
the child’s health care provider.
Non-Prescription (Over-the-Counter)Medications:
• May be administered without approval or instructions from the child’s health care provider.
• Shall be administered in accordance with the product label directions on the container.
• The instructions from the child’s parent/guardian shall not conflict with the product label directions on the
container.
AUTHO RIZATIO N FO R M ED I C AT I O N AD M I N I ST R AT I O N
I hereby authorize designated agents of (name of facility/center): _______________________________________________________
to administer the following medication to my child, ________________________________________. I further agree to indemnify
and hold harmless this facility/center, their agents, and servants against all claims as a result of any and all acts performed
under this authority.
Parent/Guardian Name ____________________________________________________ Telephone ___________________________
My child’s health care provider is _____________________________________________ Telephone ___________________________
My child’s condition is ____________________________________________________________________________________________
Purpose of medication is ___________________________________________________ Time of administration ________________
Name of medication ________________________________________________________ Duration of administration ____________
Method of administration ___________________________________________________ Possible side effects ___________________
In case of emergency, contact _______________________________________________
Telephone ___________________________
Parent/Guardian signature ________________________________________________
Today’s Date ________________________
Monthly Medication Record on back to be completed by person administering medication.

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