OCFS-LDSS-7004 (5/2014) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES MEDICATION Caregivers may use this form or an approved equivalent to document medications administered in the day care program. Documentation must be kept with the child’s written medication consent form. Any doses of the medication listed below not given must be documented. CHILD NAME: MEDICATION:(including dose) COMPLETE WHEN SIDE COMPLETE FOR NEEDED’ ‘AS COMPLETE FOR ALL DOSES GIVEN EFFECTS ARE NOTED ONLY Date Dose Time Administered by Any Noted Side Were For needed” medication Were “as – Given (AM or PM) (full signature) Effects parents write the symptoms the child parents (M/D/Y) notified exhibited that necessitated the notified “as of side need for the medication needed” effects? medicine was given Yes AM Yes No No PM Yes AM Yes No No PM Yes Yes AM No No PM Yes AM Yes No No PM Yes AM Yes No No PM Yes AM Yes No No PM Yes AM Yes No No PM Yes Yes AM No No PM Yes AM Yes No No PM Yes AM Yes No No PM Yes AM Yes No No PM Yes AM Yes No No PM AM Yes Yes No No PM Yes Yes AM No No PM AM Yes Yes No No PM AM Yes Yes No No PM AM Yes Yes No No PM AM Yes Yes No No PM
OCFS-LDSS-7004 (5/2014) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES Caregivers may use this form or an approved equivalent to document medications administered in the day care program. Documentation must be kept with the child’s written medication consent form. Any doses of the medication listed below not given must be documented. CHILD NAME: MEDICATION:(including dose) COMPLETE FOR ALL DOSES GIVEN COMPLETE WHEN SIDE EFFECTS ARE NOTED COMPLETE FOR ‘AS NEEDED’ MEDICATION ONLY Date Given (M/D/Y) Dose Time (AM or PM) Administered by (full signature) Any Noted Side Effects Were parents notified of side effects? For “as needed” medication – write the symptoms the child exhibited that necessitated the need for the medication Were parents notified “as needed” medicine was given AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No AM PM Yes No Yes No