MEDICATION LOG

Childcare Medication Log

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

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MEDICATION LOG

MEDICATION LOG

FACILITY STAFF COMPLETE THIS SECTION

FACILITY

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