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

DA Form 5225-R - also known as the "Child Development Services (cds) Medical Dispensation Record" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5225-R - was last revised on July 1, 1989. Download an up-to-date fillable PDF version of the DA 5225-R down below or look it up on the Army Publishing Directorate website.

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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EDITION OF AUG 83 IS OBSOLETE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EDITION OF AUG 83 IS OBSOLETE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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