Form Occ 1216 - Medication Administration Authorization Form - Maryland State Department Of Education
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2MARYLAND STATE DEPARTMENT OF EDUCATION
OFFICE OF CHILD CARE
MEDICATION ADMINISTRATION AUTHORIZATION FORM
Child Care Program: ________________________________________________________________
This form must be completed fully in order for child care providers and staff to administer the
required medication. A new medication administration form must be completed at the beginning
of each 12 month period, for each medication, and each time there is a change in dosage or time
of administration of a medication.
Prescription medication must be in a container labeled by the pharmacist or prescriber.
Non-prescription medication must be in the original container with the label intact.
An adult must bring the medication to the facility.
Child’s Picture
PRESCRIBER’S AUTHORIZATION
Child’s Name: ______________________________________________________ Date of Birth: ___________________________
Condition for which medication is being administered: ______________________________________________________________
Medication Name: ______________________________________Dose: ______________________Route: ___________________
Time/frequency of administration: ____________________________________________ If PRN, frequency: __________________
If PRN, for what symptoms: __________________________________________________________________________________
Possible side effects - Specify: ________________________________________________________________________________
Medication shall be administered from: ________________________________to_______________________________________
Month I Day / Year
Month I Day I Year (not to exceed 1 year)
Prescriber’s Name/Title: ___________________________________________
(Type or print)
Telephone: _________________________ FAX: _______________________
Address: _______________________________________________________
_______________________________________________________
Prescriber’s Signature: ____________________________Date:____________
(Original signature or signature stamp ONLY)
This space may used for the Prescriber’s Address Stamp
PARENT/GUARDIAN AUTHORIZATION
I/We request authorized child care provider/staff to administer the medication as prescribed by the above prescriber. I/We certify
that I/we have legal authority to consent to medical treatment for the child named above, including the administration of medication
at the facility. I/We understand that at the end of the authorized period, an adult must pick up the medication, otherwise it will be
discarded.
Parent/Guardian Signature: _______________________________________________________ Date: ______________________
Home Phone #: _____________________ Cell Phone #: _______________________ Work Phone #: _______________________
SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL
Self carry/self administration of emergency medication noted above may be authorized by the prescriber.
Prescriber’s authorization: ___________________________________________________________________________________
Signature
Date
Parental approval: _________________________________________________________________________________________
Signature
Date
FACILITY RECEIPT AND REVIEW
Medication was received from: ____________________________________________________ Date: ______________________
□
□
Special Heath Care Plan Received:
YES
NO
Medication was received by: _________________________________________________________________________________
Signature of Person Receiving Medication and Reviewing the Form
Date
OCC 1216 (Revised 10-12 – All previous editions are obsolete.)
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