Form CCL.027 "Authorization for Dispensing Medications to Children and Youth Long-Term Medications (Prescription and Non-prescription)" - Kansas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form CCL.027 for the current year.

What Is Form CCL.027?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.027 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.027 "Authorization for Dispensing Medications to Children and Youth Long-Term Medications (Prescription and Non-prescription)" - Kansas

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Kansas Department of Health and Environment
CCL.027
Rev. 5/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270 Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
Authorization for Dispensing Medications to Children and Youth
Long-Term Medications (Prescription and Non-Prescription)
Prescription medications must be in their original containers labeled with the child’s/youth’s first and last name; the name of
the licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN) who ordered the medication; the
date the prescription was filled; the expiration date of the medication; and specific, legible instructions for administration and
storage of the medication. Administer the medication only to the child designated on the prescription label in accordance with
the instructions on the label. Non-prescription medications can be given with written permission and direction from the parent
or legal guardian. Administer nonprescription medication from the original container labeled with the first and last name of the
child/youth and according to the instructions on the label.
______________________________________________________________________________________________________
First and Last Name of Child/Youth
Date of Birth
______________________________________________________________________________________________________
Name of Medication (only one medication per authorization)
Prescription OR Non Prescription
_______________________________________________________________________________________________________
Reason for Medication
_______________________________________________________________________________________________________
Dose
Time to be Given
Start Date
Stop Date**
_______________________________________________________________________________________________________
Name of Licensed Physician, PA or APRN prescribing the medication
Phone # of Physician, PA or APRN
I allow the above medication to be given to my child/youth by the designated person.
_______________________________________________________________________________________________________
Parent’s Signature
Date Signed
**Stop date not to exceed one year from the start date. A new authorization is to be completed any time the medication, dosage, times to be given, or instructions
from the parent or health care provider change from the information included on this form. Additional copies of this form may be attached to this page if more
space is needed to record the administration of the medication for up to one year if there are no changes in instructions. Above information must be completed
on each page but the parent’s signature is required only once per year.
THIS FORM IS TO BE USED TO DOCUMENT ADMINISTRATION OF ONLY THE MEDICATION IDENTIFIED ABOVE. Designated Person to
note any comments or remarks about the child’s/youth’s appearance and/or condition on the back of the form.
Date
Time
*Initials
Date
Time
*Initials
Date
Time
*Initials
mm/dd/yy
mm/dd/yy
mm/dd/yy
*Each designated person administering medication is to sign on the back side of this form and identify initials used above.
Kansas Department of Health and Environment
CCL.027
Rev. 5/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270 Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
Authorization for Dispensing Medications to Children and Youth
Long-Term Medications (Prescription and Non-Prescription)
Prescription medications must be in their original containers labeled with the child’s/youth’s first and last name; the name of
the licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN) who ordered the medication; the
date the prescription was filled; the expiration date of the medication; and specific, legible instructions for administration and
storage of the medication. Administer the medication only to the child designated on the prescription label in accordance with
the instructions on the label. Non-prescription medications can be given with written permission and direction from the parent
or legal guardian. Administer nonprescription medication from the original container labeled with the first and last name of the
child/youth and according to the instructions on the label.
______________________________________________________________________________________________________
First and Last Name of Child/Youth
Date of Birth
______________________________________________________________________________________________________
Name of Medication (only one medication per authorization)
Prescription OR Non Prescription
_______________________________________________________________________________________________________
Reason for Medication
_______________________________________________________________________________________________________
Dose
Time to be Given
Start Date
Stop Date**
_______________________________________________________________________________________________________
Name of Licensed Physician, PA or APRN prescribing the medication
Phone # of Physician, PA or APRN
I allow the above medication to be given to my child/youth by the designated person.
_______________________________________________________________________________________________________
Parent’s Signature
Date Signed
**Stop date not to exceed one year from the start date. A new authorization is to be completed any time the medication, dosage, times to be given, or instructions
from the parent or health care provider change from the information included on this form. Additional copies of this form may be attached to this page if more
space is needed to record the administration of the medication for up to one year if there are no changes in instructions. Above information must be completed
on each page but the parent’s signature is required only once per year.
THIS FORM IS TO BE USED TO DOCUMENT ADMINISTRATION OF ONLY THE MEDICATION IDENTIFIED ABOVE. Designated Person to
note any comments or remarks about the child’s/youth’s appearance and/or condition on the back of the form.
Date
Time
*Initials
Date
Time
*Initials
Date
Time
*Initials
mm/dd/yy
mm/dd/yy
mm/dd/yy
*Each designated person administering medication is to sign on the back side of this form and identify initials used above.
*Signature of Designated Person Administering Medication ___________________________________ Initialing as___________
*Signature of Designated Person Administering Medication ___________________________________ Initialing as___________
*Signature of Designated Person Administering Medication ___________________________________ Initialing as___________
*Signature of Designated Person Administering Medication ___________________________________ Initialing as___________
Note Form
Date
Additional comments about the incident or other related incidents, including
comments or remarks about the child’s/youth’s appearance and/or condition.
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