STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
NEBULIZER CARE CONSENT/VERIFICATION
CHILD CARE FACILITIES
This form may be used to show compliance with Health and Safety Code Section 1596.798 before a child care licensee or
staff person administers inhaled medication to a child in care. A copy of the completed form should be filed in the child’s
record and in the personnel file. A separate form must be filled out for each person who administers inhaled
medication to the child.
Linda Brown
I,_________________________________________, give my consent for_______________________________________,
(PRINT NAME OF AUTHORIZED REPRESENTATIVE)
(PRINT NAME OF LICENSEE OR STAFF PERSON)
Pacific Beach Early Learning Center, 1779 Law Street, San Diego, CA 92109
who work(s) at ____________________________________________________________________________________,
(PRINT NAME AND ADDRESS OF CHILD CARE FACILITY)
to administer inhaled medication to my child,_________________________________, and to contact my child’s health care
(PRINT NAME OF CHILD)
provider.
In addition, I certify that I have personally instructed the above-named licensee or staff person on how to administer inhaled
medication to my child.
I have also provided the child care facility with written instructions from my child’s physician, or from a health care provider
working under the supervision of my child’s physician (for example, a physician’s assistant, nurse practitioner or registered
nurse). These instructions include:
•
Specific indications (such as symptoms) for administering the inhaled medication in accordance with the physician’s
prescription.
•
Potential side effects and expected response.
•
Dose form and amount to be administered in accordance with the physician’s prescription.
•
Actions to be taken in the event of side effects or incomplete treatment response in accordance with the physician’s
prescription. This includes actions to be taken in an emergency.
•
Instructions for proper storage of the medication.
•
The telephone number and address of the child’s physician.
SIGNATURE OF AUTHORIZED REPRESENTATIVE
DATE
ADDRESS OF AUTHORIZED REPRESENTATIVE
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
LIC 9166 (2/01)
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