Medication Administration Form | UNL Children's Center

Before bringing a medication to the Children’s Center, follow this Safety Checklist:

It’s in the original container / packaging.
The original prescription or manufacturer’s label with the name and strength of the medicine are on the container.
The child’s full name on the container is correct (must include first and last name)
The current date on the prescription / expiration label covers the period when medicine is to be administered.
The name and phone number for the licensed healthcare professional who ordered the medication is on the container or is on file.
Instructions are clear for dose, route, and time to give the medicine.
Instructions are clear for storage (e.g. temperature) and the medication has been safely stored prior to arriving at the Children’s Center.
The child had received at least one dose of the medicine without adverse effects.
For PRN medicine, a doctor's note is attached.

Today's Date Required

Child's Full Name Required

Date of Birth Required

Name of Medicine Required

Reason medicine is needed during school hours Required

Dose Required

example: 1 tsp every 4 hours.

Route Required

Time to give medicine Required

Additional instructions Required

Start Date for medicine Required

Stop Date for medicine Required

Permission to Give Medicine Required

By clicking the box, I hereby give permission and deemed competent the facility/school to administer medicine as prescribed above. I also give permission for the caregiver/teacher to contact the prescribing health professional about the administration of this medicine. I have administered at least one dose of medicine to my child without adverse effects.

Parent/Guardian Name Required

Phone Number