Form Lic 622b - Psychotropic Medication Administration Record (Mar)
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4CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
COMMUNITY CARE LICENSING
PSYCHOTROPIC MEDICATION ADMINISTRATION RECORD (MAR)
NOTE: Fill out a separate LIC 622B for each psychotropic medication the child is currently taking (HSC§ 1507.6[b][2][B].
Child’s Name:
JV223 Date:
Date of Birth:
Sex:
Facility Name & Number or Foster/Certified/Resource Family Agency Name:
MO/YR:
Prescription Details
Time
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Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Allergies:
Additional Instructions From Physician:
Date of Last Lab:
Anticipated Refill Date:
Date and Description Of Any Observed Side Effects:
Pharmacy Name & Number:
Physician Name & Number:
Monthly Weight & Date:
A.
Fill in what time the child takes the medication.
B.
Put initials in appropriate box when medication is given.
C.
Circle initials when not given.
Placement Worker Name & Number:
D.
State reason for refusal / omission on page 2 of 2.
E.
S = School; H = Home visit; W = Work; P = Program; R = Refusal; O = Other.
HOME VISITS (Leaving)
HOME VISITS (Returning)
Initials of
Initials of
Signature of Authorized
Signature of Authorized
Person
Person
Date
Name Of Medication
Quantity
Representative Receiving
Date
Name Of Medication
Quantity
Representative
Releasing
Receiving
Medication
Releasing Medication
Medication
Medication
LIC 622B (5/17)
PAGE 1 OF 4
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