Form Occ 1216 - Medication Administration Authorization Form - Maryland State Department Of Education Page 2

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MEDICATION ADMINISTERED
Each administration of a medication to the child shall be noted in the child’s record, except for the application of a
preventive, nonprescription product applied to unbroken skin (such as diaper ointments, sunscreen, lip balm, or insect
repellent) supplied by the child’s parent. Keep this form in the child’s permanent record while the child remains in the
care of this provider or facility.
Child’s Name:
Date of Birth:
Medication Name:
Dosage:
Route:
Time(s) to administer:
DATE
TIME
DOSAGE
REACTIONS OBSERVED (IF ANY)
SIGNATURE
OCC 1216 (Revised 10-12 – All previous editions are obsolete.)
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