DA Form 5225-R "Child Development Services (Cds) Medical Dispensation Record"

What Is DA Form 5225-R?

This is a military form that was released by the U.S. Department of the Army (DA) on July 1, 1989. The form, often mistakenly referred to as the DD Form 5225-R, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 2-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;
  • Fill out the form in our online filing application.

Download an up-to-date fillable DA Form 5225-R down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 5225-R "Child Development Services (Cds) Medical Dispensation Record"

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MONTH
CHILD DEVELOPMENT SERVICES (CDS) MEDICAL DISPENSATION RECORD
For use of this form, see AR 608-10; the proponent agency is DCSPER.
(SEE REVERSE FOR PRIVACY ACT STATEMENT)
NAME OF CHILD
ACTIVITY ROOM
NAME OF SPONSOR
HOME PHONE
DUTY PHONE
MEDICATION
AUTHORIZING PHYSICIAN
MEDICAL FACILITY
TELEPHONE
(One per card)
YES
NO
INCLUSIVE DATES
DOSAGE
TIME
INSTRUCTIONS: REFRIGERATION
BEGIN
FINISH
*CDS PERSONNEL DISPENSING MEDICINE WILL INDICATE TIME OF ADMINISTRATION AND INITIAL SAME WITHIN EACH TIME
BLOCK ON A GIVEN DATE.
*1
*2
*3
*4
*5
*6
*7
*8
*9
*10
*11
*12
*13
*14
*15
*16
*17
*18
*19
*20
*21
*25
*26
*27
*28
*22
*23
*24
*29
*30
*31
DA FORM 5225-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
APD LC v2.01ES
MONTH
CHILD DEVELOPMENT SERVICES (CDS) MEDICAL DISPENSATION RECORD
For use of this form, see AR 608-10; the proponent agency is DCSPER.
(SEE REVERSE FOR PRIVACY ACT STATEMENT)
NAME OF CHILD
ACTIVITY ROOM
NAME OF SPONSOR
HOME PHONE
DUTY PHONE
MEDICATION
AUTHORIZING PHYSICIAN
MEDICAL FACILITY
TELEPHONE
(One per card)
YES
NO
INCLUSIVE DATES
DOSAGE
TIME
INSTRUCTIONS: REFRIGERATION
BEGIN
FINISH
*CDS PERSONNEL DISPENSING MEDICINE WILL INDICATE TIME OF ADMINISTRATION AND INITIAL SAME WITHIN EACH TIME
BLOCK ON A GIVEN DATE.
*1
*2
*3
*4
*5
*6
*7
*8
*9
*10
*11
*12
*13
*14
*15
*16
*17
*18
*19
*20
*21
*25
*26
*27
*28
*22
*23
*24
*29
*30
*31
DA FORM 5225-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
APD LC v2.01ES
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
Title 10, United States Code, Section 3013.
To provide sponsor consent for administration of medication, confirm medication dispensation directions,
PRINCIPAL PURPOSE(S):
maintain medication records, and identify individuals responsible for dispensing medication.
No information is to be disclosed outside DOD.
ROUTINE USES:
Disclosure of requested information is voluntary, however, if information is not provided, medication will not be
DISCLOSURE:
administered.
CDS PERSONNEL AUTHORIZED TO ADMINISTER MEDICATION TO
(Child's Name)
I,
hereby authorize the
CDS personnel noted above to administer medication in the quantity and manner as requested and release same from all legal claims
issued due to injury or illness which may result from such administering. Additional CDS personnel may be designated at the
discretion of the CDS Program Director.
(Date)
(Signature of Sponsor)
DATE
SIGNATURE OF PROGRAM DIRECTOR
REVERSE OF DA FORM 5225-R, JUL 1989
APD LC v2.01ES
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