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Prescription Permission Form

Authorization for the Administration of Medication by Child Day Care Personnel

In Connecticut, licensed Child Day Care Centers, Group Day Care Homes and Family Day Care Homes administering medications to children shall comply with all requirements regarding the Administration of Medications described in the State Statutes and Regulations. Parents/guardians requesting medication administration to their child by daycare staff shall provide the program with appropriate written authorization(s) and the medication before any medications are dispensed. Medications must  be  in  the  original  container  and  labeled  with  child’s  name,  name  of  medication,  directions  for  medication’s   administration, and date of the prescription. All unused medication will be destroyed if not picked up within one week following  the  termination  of  the  authorized  prescriber’s  order.

ALL INFORMATION IS REQUIRED. FAILURE TO FILL OUT ALL FIELDS WILL RESULT IN HAVING TO START OVER.

Authorized  Prescriber’s  Order (Physician, Dentist, Physician Assistant, Advanced Practice Registered Nurse):

Name of Child: Date of Birth: Today's Date:

Name of Medication: Controlled Drug? Yes No

Dosage: Method: Time of Administration:

Specific Instructions for Medication Administration:

Medication Administration Start Date: Stop Date:

Is this medication to be self-administered by the child? Yes No

Relevant Side Effects of Medication:

Plan of Management for Side Effects:

Known Food or Drug Allergies? Yes No - Reactions to? Yes No - Interactions with? Yes No

If "yes" to any of the above, please explain:

Prescriber's Name: Phone Number:

Prescriber's Address: Town:

Signature: 

Parent/Guardian Authorization:

I request that medication be administered to my child as described and directed above and attest that I have administered at least one dose of the medication to my child without adverse effects.

I request that medication be self-administered to my child as described and directed above.

Name of Daycare Program: Today's Date:

Name of Child: Address: Town:

Name of Parent/Guardian Authorizing Administration of Medication:

Relationship to Child: Mother Father Guardian/Other explain:

Address: Town: Phone Number:

Signature of Parent/Guardian Authorizing Administration of Medication:

Parent/Guardian Email Address:

 

Medication Administration Record (MAR)

Name of Child: Date of Birth:

Pharmacy Name: Prescription Number:

Medication Order:

Date Time Dosage Remarks Was This Medication Self Administered? Signature of Person Observing or Administering Medication
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Authorization form is complete Medication is appropriately labeled

Medication is in original container Date on label is current

Person Accepting Medication (print name): Date:

 

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