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    Administration of Medication

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    Amanda's Garden
    The document is a request form for administration of medication in child care centers and type A homes in Ohio. It requires information from parents/guardians about the child's name, medication, dosage instructions, and signature. For some medications, it also requires information from a licensed physician, dentist, or nurse practitioner about the medication, dosage, possible side effects, and signature. The form is valid for up to 12 months and a new form is needed for each medication. Staff must document each administration of medication on the form.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Administration of Medication

    Uploaded by

    Amanda's Garden
    276 views0 pages
    The document is a request form for administration of medication in child care centers and type A homes in Ohio. It requires information from parents/guardians about the child's name, medication, dosage instructions, and signature. For some medications, it also requires information from a licensed physician, dentist, or nurse practitioner about the medication, dosage, possible side effects, and signature. The form is valid for up to 12 months and a new form is needed for each medication. Staff must document each administration of medication on the form.

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    Administration of Medication

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    The document is a request form for administration of medication in child care centers and type A homes in Ohio. It requires information from parents/guardians about the child's name, medication, dosage instructions, and signature. For some medications, it also requires information from a licensed physician, dentist, or nurse practitioner about the medication, dosage, possible side effects, and signature. The form is valid for up to 12 months and a new form is needed for each medication. Staff must document each administration of medication on the form.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    276 views0 pages

    Administration of Medication

    Uploaded by

    Amanda's Garden
    The document is a request form for administration of medication in child care centers and type A homes in Ohio. It requires information from parents/guardians about the child's name, medication, dosage instructions, and signature. For some medications, it also requires information from a licensed physician, dentist, or nurse practitioner about the medication, dosage, possible side effects, and signature. The form is valid for up to 12 months and a new form is needed for each medication. Staff must document each administration of medication on the form.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 0

    Ohio Department of Job and Family Services

    REQUEST FOR ADMINISTRATION OF MEDICATION


    Child Care Centers and Type A Homes

    This form must be used by child care centers and type A homes to meet the requirement of OAC rules 5101:2-12-31 and 5101:2-13-31

    JFS 01217 (Rev. 9/2005) Page 1 of 2
    This form is valid for no longer than twelve (12) months. One form must be used for each medication.

    Box 1 - The following section must always be completed by the parent/guardian.

    Check all that apply:

    Prescription medication Topical product or lotion
    Nonprescription medication Food supplement
    Refrigeration required Modified diet

    Complete all of the following information:

    Name of child:___________________________________ Date of birth: _______________Weight: __________

    Name of medication:______________________________ Exact dosage: _______________________________

    To be administered at the following times_________________________________________________________

    For the following period of time:________________________________________________________________

    Parent/Guardian signature:________________________________________________ Date: _______________


    Box 2 -The following section must be completed by a licensed physician, a licensed dentist or an advance
    practice nurse when:
    1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or
    underweight per the label instructions); or
    2. It is a sample medication without a prescription label; or
    3. The nonprescription medication is to be given longer than three consecutive days within a fourteen day
    period or is a topical product or lotion that is being used for a skin ailment and is to be applied longer than
    fourteen consecutive days; or
    4. The child is on a modified diet (an entire food group is eliminated) or food supplement; or
    5. The medication contains codeine or aspirin.


    _________________________________ is under my care and should receive _____________________________
    (name of child) (name of medication, vitamin, diet)

    as follows: ___________________________________________________________________________________
    (include dosage and instructions)

    Possible side effects to watch for are: ______________________________________________________________

    Expiration date: _______________ (May not exceed 12 months from the date of this request for medications or food
    supplements)

    ______________________________________________ _________________ ___________________________
    Signature of physician, dentist or advance practice nurse Date of signature Phone number


    Reset Form
    This form must be used by child care centers and type A homes to meet the requirement of OAC rules 5101:2-12-31 and 5101:2-13-31

    JFS 01217 (Rev. 9/2005) Page 2 of 2

    Box 3 - The section below must be completed by the center or type A home staff and each administration of
    medication must be documented. All dosages must be recorded on page 2 of this form.



    _______________________________ was given ____________________ in the amount of _______________
    (Name of Child) (Name of Medication, (Dosage)
    Vitamin or Diet)


    Date and Time of Dosage Dosage Amount Signature of Designated Person Administering Medication

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