Medication Administration Form - California Childcare Health Program Page 2
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1
2MoNthly MediCatioN ReCoRd
Name of Child ________________________________________________
Dates to administer
Dosage
Time of
Staff signature
Staff signature
Parent initial to
amount
administration
and time given
second time given
acknowledge
(if required)
administration
Monday
Date:
tuesday
Date:
Wednesday
Date:
thursday
Date:
Friday
Date:
Monday
Date:
tuesday
Date:
Wednesday
Date:
thursday
Date:
Friday
Date:
Monday
Date:
tuesday
Date:
Wednesday
Date:
thursday
Date:
Friday
Date:
Monday
Date:
tuesday
Date:
Wednesday
Date:
thursday
Date:
Friday
Date:
Any additional comments and/or observations with staff initials: ________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Completed form and corresponding documentation is to be kept on-site in the child’s file.
California Childcare Health Program • 1950 Addison Street, Suite 107 • Berkeley, CA 94704-1182
510–204-0930 •
510–204-0931 •
1-800-333-3212 •
Telephone
Fax
Healthline
07/08
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Parent category: Medical