This form is valid for no longer than twelve months and must be kept on file at the center or home for at least one year following the
last administration of the medication or product. One form must be used for each medication.
JFS 01217 (Rev. 12/2016) Page 1 of 2
Ohio Department of Job and Family Services
REQUEST FOR ADMINISTRATION OF MEDICATION
FOR CHILD CARE
The following section must always be completed by the parent/guardian.
Check all that apply and complete all of the information.
Prescription Medication Nonprescription Medication Food Supplement
Topical Product or Lotion Refrigeration Required Modified Diet
To be administered at the following times
For the following period of time
I understand that my child must receive one dose of medication before arriving at the program (unless the
medication is used for emergencies).
Signature of Parent/Guardian
The following section must be completed by a licensed physician, licensed dentist, advanced practice
registered nurse or certified physician's assistant.
1. The medication contains codeine or aspirin.
2. A physician's instruction is needed for a nonprescription medication (e.g. child does not meet minimum age or
weight requirements as listed on the label instructions).
3. It is a sample medication without a prescription label.
4. The nonprescription medication is to be given longer than three consecutive days within a fourteen day period.
5. The topical product or lotion and the physician’s instructions exceed the manufacturer's instructions or use.
Name of medication, vitamin, diet, supplement
Possible side effects to watch for are
Expiration date
(May not exceed twelve months from the date of this request for medications of food supplements).
This child is under my care and should receive the above medication as written.
Signature of physician, dentist, advanced practice registered nurse or certified physician's assistant
Name of medication, vitamin, diet, supplement
