MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION
MEDICATION AUTHORIZATION
MO 580-1875 (6-14)
FORM TO BE RETAINED IN CHILD’S RECORD
BCC-11
MEDICATION REQUIREMENT
RECORD OF ADMINISTRATION
PRESCRIPTION MEDICA
TION SHALL BE IN THE ORIGINAL CONTAINER AND LABELED WITH THE CHILD’S NAME, INSTRUCTIONS,
INCLUDING TIMES AND AMOUNTS FOR DOSAGES, AND THE PHYSICIAN’S NAME. ALL NON-PRESCRIPTION MEDICATION SHALL
BE IN THE ORIGINAL CONTAINER AND LABELED BY THE PARENT(S) WITH THE CHILD’S NAME AND INSTRUCTIONS FOR
ADMINISTRATION, INCLUDING TIMES AND AMOUNTS FOR DOSAGES. A SEPARATE FORM IS NEEDED FOR EACH MEDICATION.
THIS FORM IS VALID ONLY FOR THE DATES INDICATED BELOW.
I AUTHORIZE CHILD CARE PERSONNEL TO ADMINISTER THE FOLLOWING MEDICATION TO MY CHILD:
(PROPER NAME OF MEDICATION)
CHILD’S FULL NAME DA
TE MEDICATION TAKEN FROM UNTIL
DOSAGE TIME(S) OF DA
Y
POSSIBLE SIDE EFFECTS
SIGNATURE OF PARENT(S) OR GUARDIAN DATE
STAFF NAME DATE MEDICATION NAME DOSAGE TIME
