Free template
Medication permission and dose log
One sheet per child and medication. The top half is the parent's signed, dated permission; the bottom half records every dose with the date, time, amount and who gave it. The fields are the ones New Jersey, Maine and Texas list.
Permission to give medication
Child's full name
Medication
What it is for
Dose and how often
Start date
End date
Possible side effects
Prescribed by
I give permission for the center to give my child this medication as written above.
Parent's signature
Printed name
Date
Each dose given
| Date | Time | Amount given | Given by (full name) | Any reaction, and parent told |
|---|---|---|---|---|
Keep the medication in its original container, labeled with the child's name. Texas asks for the records to be kept at least three months.
What the rules ask for
- New Jersey (N.J.A.C. 3A:52-7.5(b)7)“The child's name and parental authorization ...; The name of the medication ...; The condition for which the medication ... is being used; The instructions for administration, including the dosage and frequency; The date and time medication ... was administered to a child and the name or initials of the staff member who administered it; and Any adverse effect the medication can have or has had on the child”
- Maine (10-148 CMR Ch. 32, §12(H), (H)(3))“A Child Care Facility may give a Child prescription medication only when the Child Care Facility has written, signed, and dated permission from a Parent. ... The Child Care Facility must keep a written record, noting each time a prescription and nonprescription medication is given to a Child.”
- Texas (26 TAC §746.3805(c), (d))“Full name of the child to whom the medication was given; Name of the medication; Date, time, and amount of medication given; and Full name of the employee administering the medication. ... You must keep all medication records for at least three months after administering the medication.”
New Jersey allows the staff member's initials; Texas asks for their full name, so the sheet asks for the full name.
Or sign and record it on a phone
In Farlow, the parent signs the medication form from their phone, each dose is recorded with who gave it, and the family taps that they were told.
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