Form Lic 622a - Medication Administration Record (Mar)
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4CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
COMMUNITY CARE LICENSING
MEDICATION ADMINISTRATION RECORD (MAR)
NOTE: This form should be used for all non-psychotropic medication.
Child’s Name:
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:
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Allergies:
Date and Description of Any Observed Side Effects:
Monthly Weight & Date:
Anticipated Refill Date:
.
Pharmacy Name & Number:
Physician Name & Number:
A
Fill in what time the child takes the medication in the “TIME” column.
B.
Put initials in appropriate box when medication is given.
C.
Circle initials when not given.
Additional Instructions From Physician:
D.
State reason for refusal / omission on page 2 of 2.
E.
PRN Medications: Reason given and results must be noted on page 2 of 2.
Placement Worker Name & Number:
F.
S = School; H = Home visit; W = Work; P = Program; R = Refusal; O = Other
LIC 622A (6/17)
PAGE 1 OF 4
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