1050
First St. NE, 6
th
Floor, Washington, DC 20002 • Phone: (202) 727-1839 TTY: 711 • osse.dc.gov
Medication Authorization Form
Pursuant to Title 5A, Chapter 1 of the District of Columbia Municipal Regulations (DCMR), Section 153.1;“A Licensee shall not
administer medication or treatment to a child in care, with the exception of emergency first aid, whether prescription or non-
prescription, unless: parental permission to administer the medication or treatment is documented on a completed, signed, and
dated medication authorization form that is received by the Licensee before the medication or treatment is administered or a
licensed health care practitioner has approved the administration of the medication and the medication dosage.”
Pursuant to Title 5A, Chapter 1 of the District of Columbia Municipal Regulations (DCMR), Section 153.5,"A Licensee shall
maintain a medication log, on a form approved by OSSE. Each time medication is administered to a child, a staff person shall
enter the date, time of day, medication, medication dosage, method of administration, and the name of the person administering
the medication in the medication log.
Part I: To be completed by the parent/guardian and child’s physician:
I do hereby give permission to ___________________________________ to administer the following
Name of Facility
prescribed medication to my child ___________________________________ born on ____________.
Name of Medication
Time/Frequency
Dosage
Effective Dates
From:
To:
From:
To:
_________________________________________ _______________________
Signature of Physician Date
__________________________________________ _______________________
Signature of Parent/Guardian Date
Part II: To be completed by the center director or staff administering medication who has
current medication administration certificate:
Name of Medication
Date
Time Given
Staff
Initials
PLEASE PLACE A COPY IN THE CHILD’S FILE.
(Rev.
07-2018)
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