Ocfs.ny.gov
OCFS-LDSS-7004 (5/2014) FRONT
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
Log of Medication Administration
• 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 |COMPLETE FOR ‘AS NEEDED’ MEDICATION ONLY |
| |NOTED | |
|Date Given |Dose |Time |Administered by |Any Noted Side Effects |Were |For “as needed” medication – write the |Were parents |
|(M/D/Y) | |(AM or PM) |(full signature) | |parents |symptoms the child exhibited that |notified “as |
| | | | | |notified |necessitated the need for the medication |needed” |
| | | | | |of side | |medicine was |
| | | | | |effects? | |given |
| | | | AM |
| | | |PM |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
| | | Yes | |
| | |No | |
|Notes: |
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