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Maryland state department of education

MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
MEDICATION AUTHORIZATION FORM
Regulations permit child care providers to give prescription and non-prescription medication to children in care under certain
conditions with prior written permission (Section A) from the child’s parent. A separate form is needed for each prescription or non-
prescription medication to be administered to the child.
PRESCRIPTION MEDICATIONS AND NON-PRESCRIPTION MEDICATIONS: Prescription medications must be in a
container labeled by the pharmacy or physician with the child’s name, dosage, and expiration date. At least one dose of prescription
medication must be given at home prior to the child’s arrival at the child care facility. Non-prescription medications must be in the
original manufacturer’s container labeled with instructions for dosage and expiration date. Except for acetaminophen (Tylenol) and
topical medications, a provider may administer only one dose of nonprescription medication to a child per illness unless a licensed
health practitioner provides written approval (Section B) of the administration of the nonprescription medication and the dosage OR
Sections B and C may be completed by the provider if verbal permission is obtained from the health practitioner/designee. All
medication shall be administered according to the instructions on the label of the medication container or a licensed health
practitioner’s written/verbal instructions, whichever are more recently dated.
Name of Child: ___________________________________________________________________ Date of Birth: ______________
SECTION A:
MEDICATION
WHEN TO GIVE
DATES TO ADMINISTER
This medication is being given for the following condition(s):
ADDITIONAL INSTRUCTIONS (including instructions not given on the prescription):
Note any side effects of this medication:
Note any reasons or conditions when this medication should be stopped or not given:
I authorize ____________________________________ to administer the above named medication to my child.
Name of Child Care Provider or Facility
Signature of Parent/Guardian: _________________________________________ Date: ___________________
SECTION B:
PHYSICIAN’S APPROVAL IF MORE THAN
ONE DOSE OF NON-PRESCRIPTION MEDICATION IS TO BE GIVEN
(OTHER THAN ACETAMINOPHEN (TYLENOL) OR TOPICAL MEDICATIONS)
Instructions for more than one dose of a non-prescription medication:
Note any side effects of this medication:
Note any reasons or conditions when this medication should be stopped or not given:

Signature of Health Practitioner:
Stamp, Print or Type Name of Health Practitioner:

SECTION C:
If Section B is not signed by the health practitioner, the health practitioner/designee may give oral permission and instructions to
the provider directly. If oral permission and instruction is given, the provider must complete Section B and the following:
Name of Practitioner/Designee giving approval:
Signature of person receiving approval from health practitioner/designee:
OCC 1216 - Revised 6/08 - All previous editions are obsolete. Page 1 of 2 MEDICATION ADMINISTERED
Except for the application of a nonprescription diaper rash treatment, sunscreen, or insect repellent supplied by the child’s
parent, each administration of a medication to the child shall be noted in the child’s record. Keep this form in the child’s
permanent record while the child remains in the care of this provider or facility.

Child’s Name:
Date of Birth:

Medication:
REACTIONS OBSERVED (IF ANY)
SIGNATURE
OCC 1216 - Revised 6/08 - All previous editions are obsolete. Page 2 of 2

Source: http://www.clcpreschool.net/pdf/1216ALL2Jun08.pdf