Authorization To Administer Prescription And Non Prescription Medication Template
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1AUTHORIZATION TO ADMINISTER PRESCRIPTION AND NON PRESCRIPTION MEDICATION
IN ACCORDANCE WITH HE C 4002.20, THIS FORM MUST BE COMPLETED PRIOR TO THE ADMINISTRATION OF ANY PRESCRIPTION OR NON
PRESCRIPTION MEDICATION
PRESCRIPTION MEDICATION WILL BE ADMINISTERED IN ACCORDANCE WITH THE PRINTED PRESCRIPTION LABEL, WHICH MUST BE
ATTACHED TO THE ORIGINAL PRESCRIPTION CONTAINER.
NON PRESCRIPTION MEDICATION MUST BE IN ORIGINAL CONTAINER, AND WILL BE ADMINISTERED IN ACCORDANCE WITH THE
MANUFACTURER’S PRINTED INSTRUCTIONS. IF THERE ARE NO MANUFACTURER'S PRINTED INSTRUCTIONS FOR THE AGE OF THE
CHILD, THE PROGRAM MAY ADMINISTER THE NON-PRESCRIPTION MEDICATION IN ACCORDANCE WITH THE WRITTEN, DATED AND
SIGNED INSTRUCTIONS FROM THE CHILD’S PARENT, INCLUDING A STATEMENT THAT THE INSTRUCTIONS HAVE BEEN
REVIEWED/APPROVED BY THE CHILD'S LICENSED HEALTH PRACTITIONER, OR WITH SIGNED, DATED WRITTEN INSTRUCTIONS FROM
CHILD'S LICENSED HEALTH PRACTITIONER.
PARENT’S AUTHORIZATION
I AUTHORIZE CHILD CARE PERSONNEL AT___________________________________________________________________________________
NAME OF CHILD CARE PROGRAM
TO ADMINISTER THE FOLLOWING MEDICATION TO MY CHILD: ________________________________________________________________
_________________
CHILD NAME
DATE OF BIRTH
NAME OF MEDICATION
DOSAGE
TIMES TO ADMINISTER
BEGINNING DATE
ENDING DATE
___________________________________________
__________________________
__________________________
______________
______________
_
___________________________________________
__________________________
__________________________
______________
______________
_
___________________________________________
__________________________
__________________________
______________
______________
_
__________________________________________________________________________________________________________________________________________
_______________
PRINTED NAME AND PHONE NUMBER OF CHILD'S LICENSED HEALTH PRACTITIONER
_________________________________________________________________________________________
_____________________________
PARENT/GUARDIAN’S SIGNATURE
DATE SIGNED
SPECIAL INSTRUCTIONS FOR ADMINISTRATION OF NON-PRESCRIPTION MEDICATION:
THE ABOVE SPECIAL INSTRUCTIONS WERE:
REVIEWED AND APPROVED BY THE ABOVE NAMED LICENSED HEALTH PRACTITIONER
COMPLETED BY THE LICENSED HEALTH PRACTITIONER WHO'S SIGNATURE IS BELOW
_________________________________________________________________________________________________________
______________
LICENSED HEALTH PRACTITIONER’S SIGNATURE
DATE SIGNED
CHILD CARE PROGRAM RECORD OF MEDICATION ADMINISTRATION
(TO BE COMPLETED BY CHILD CARE PERSONNEL FOR ALL MEDICATION ADMINISTERED)
NAME OF
NAME OF
MEDICATION
AMOUNT
TIME
DATE
INITIALS
MEDICATION
AMOUNT
TIME
DATE
INITIALS
NAME OF
NAME OF
MEDICATION
AMOUNT
TIME
DATE
INITIALS
MEDICATION
AMOUNT
TIME
DATE
INITIALS
_________________________________________________________________________________________________________________
___________________
SIGNATURE AND POSITION TITLE OF PERSON SUPERVISING ADMINISTRATION/CONTROL OF MEDICATION
DATE SIGNED
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t:\e_arch\group\configuration\librarydocs\ops\bccl\sample packet\2000 medication authorization.doc
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