Authorization to Administer Medication - Child Care Centers, DCF-F

AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS. Use of form: This form is mandatory for family child care centers to comply with ...

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DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education DCF-F (CFS-0059) (R. 02/2009)

STATE OF WISCONSIN

Page 1 of 2

AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS Use of form: This form is mandatory for family child care centers to comply with DCF 250.07(6)(f)1.a. Failure to comply may result in issuance of a noncompliance statement. This form is voluntary for group child care centers, day camps and certified providers; however, completion of this form meets the requirements of DCF 251.07(6)(f)1.a., DCF 252.44(6)(e)1.a. and DCF 202.08(4)(f) and 202.09(5)(c)., Wis. Admin. Codes. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Instructions: When a parent is requesting prescription or non-prescription medication be administered to a child in care, this form shall be completed and signed by the parent or guardian before any medication is administered. A separate form shall be used for each medication. Place form in child's file when medication is no longer required / authorized. Licensed Child Care Centers: Log the dates and times medication was administered in the center medical log. Blanket authorizations that exceed the length of time specified on the label are prohibited; no medication intended for use by a child in the care of the center may be kept at the center without a current medication administration authorization from the parent. A. FACILITY AND CHILD INFORMATION Name – Child Care Center Name – Child

Birthdate (mm/dd/yyyy)

B. MEDICATION INFORMATION: Medication shall be in the original container and labeled with the child’s name. The label shall include dosage and directions for administration. Dates – Medication Time Period Time(s) of Day to be How to be Name – Medication Dosage Administered Administered From To AM

PM

AM

PM

AM

PM

AM

PM

Yes No Does the over-the-counter (OTC) medication label indicate the child’s physician should be consulted? If “Yes” I have consulted with my child’s physician, and I am authorizing a dosage consistent with the physician’s recommendation. Name – OTC Medication Parent Initials Additional information / special instructions / contraindications – Specify.

C. AUTHORIZATION I hereby authorize administration of the above medication to my child by staff of the child care center listed above. SIGNATURE – Parent or Guardian

Date Signed

DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education DCF-F (CFS-0059) (R. 02/2009)

STATE OF WISCONSIN

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Documentation of Medication Administration – Certified Child Care Providers Instructions: This section is to be completed only by certified child care providers to document the actual administration of the medication. Licensed child care centers do not complete this portion of the form because documentation of the administration of medications must be entered into the center medical log on the day that the medication is administered. Record administration of the authorized medication in the spaces provided below. Lines should not be skipped. Date Administered 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

Time Administered

Dosage

Signature / Initials of Person Who Administered the Medication

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