MEDICATION LOG (The Club House)

Childcare Medication Log (STEAM)

MEDICATION LOG

55 Pa. Code 3270.133; 3280.133; 3290.133

Child’s Name:

Medication:

Radio Buttons

Prescription

Non-Prescription

Refrigeration Required:

Yes

No

If Prescription, Prescriber’s Name:

Telephone:

Dosage Amount:

Time to Administer (a.m)

Time to Administer (p.m)

times/day

Dates for Administration:

From

Date

To

Date

Special instructions i.e., symptoms signaling need for administration, medication indications, reasons to hold medication,

I give permission to administer medication to my child as stated above.

Parent Signature

Date

FACILITY STAFF COMPLETE THIS SECTION

FACILITY

Date Administrated

Time Administrated (a.m)

Time Administrated (p.m)

Amount of Medication Administrated

Comments/Reactions

Staff Initials

End Section

This information is confidential and may not be shared or released without the parent’s written permission.

CY 862 10/04

For additional information on Somerset Academy Early Learning Center

Contact Us

MEDICATION LOG (The Club House)

MEDICATION LOG

FACILITY STAFF COMPLETE THIS SECTION

FACILITY

For additional information on Somerset Academy Early Learning Center

Somerset Academy Early Learning Center

Membership

Partnerships

Contacts

Hours of Operation

Get Social with us