Form Ldss-7002 - Medication Consent Form - Child Day Care Programs
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2OCFS-LDSS-7002 (5/2015) FRONT
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
MEDICATION CONSENT FORM
CHILD DAY CARE PROGRAMS
This form may be used to meet the consent requirements for the administration of the following: prescription
medications, oral over-the-counter medications, medicated patches, and eye, ear, or nasal drops or sprays.
Only those staff certified to administer medications to day care children are permitted to do so.
One form must be completed for each medication. Multiple medications cannot be listed on one form.
Consent forms must be reauthorized at least once every six months for children under 5 years of age and at least once
every 12 months for children 5 years of age and older.
LICENSED AUTHORIZED PRESCRIBER COMPLETE THIS SECTION (#1 - #18) AND AS NEEDED (#33 - 35).
1. Child’s First and Last Name:
2. Date of Birth:
3. Child’s Known Allergies:
4. Name of Medication (including strength):
5. Amount/Dosage to be Given:
6. Route of Administration:
7A. Frequency to be administered:
OR
7B. Identify the symptoms that will necessitate administration of medication: (signs and symptoms must be observable and, when
possible, measurable parameters):
8A. Possible side effects:
See package insert for complete list of possible side effects (parent must supply)
AND/OR
8B: Additional side effects:
9. What action should the child care provider take if side effects are noted:
Contact parent
Contact health care provider at phone number provided below
Other (describe):
10A. Special instructions:
See package insert for complete list of special instructions (parent must supply)
AND/OR
10B. Additional special instructions: (Include any concerns related to possible interactions with other medication the child is receiving or
concerns regarding the use of the medication as it relates to the child’s age, allergies or any pre-existing conditions. Also describe
situation's when medication should not be administered.)
11. Reason for medication (unless confidential by law):
12. Does the above named child have a chronic physical, developmental, behavioral or emotional condition expected to last 12 months
or more and requires health and related services of a type or amount beyond that required by children generally?
No
Yes If you checked yes, complete (#33 and #35) on the back of this form.
13. Are the instructions on this consent form a change in a previous medication order as it relates to the dose, time or frequency the
medication is to be administered?
No
Yes If you checked yes, complete (#34 -#35) on the back of this form.
14. Date Health Care Provider Authorized:
15. Date to be Discontinued or Length of Time in Days to be Given:
16. Licensed Authorized Prescriber’s Name (please print):
17. Licensed Authorized Prescriber’s Telephone Number:
18. Licensed Authorized Prescriber’s Signature:
X
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