DJJ Form HS021 "Parental Notification of Health-Related Care: Medication Management" - Florida

What Is DJJ Form HS021?

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

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form HS021 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

ADVERTISEMENT
ADVERTISEMENT

Download DJJ Form HS021 "Parental Notification of Health-Related Care: Medication Management" - Florida

Download PDF

Fill PDF online

Rate (4.8 / 5) 47 votes
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PARENTAL NOTIFICATION OF
HEALTH-RELATED CARE: MEDICATION MANAGEMENT
(Not for Psychotropic Medications)
N
Y
: ______________________________ D
B
: ____________
AME OF
OUTH
ATE OF
IRTH
F
N
: _______________________ DJJID#: __________ D
: __________
ACILITY
AME
ATE
P
/
:
ARENT
GUARDIAN NAME AND ADDRESS
DJJ F
: __________________________________________________________
ACILITY NAME AND ADDRESS
_____________________________________________________________________________________
Dear
:
Our records indicate that you are the parent(s) or guardian who has authority over health care for the above
named youth. The purpose of this form is to notify you that a licensed health care practitioner has
recommended the following medication or medication changes.
The following medication has been ordered, started or changed:
Medication: _________________________________
_____times per day, by _________for _____days
(route)
Purpose: ______________________________________________________________________________
Possible Side Effects:_____________________________________________________________________
_______________________________________________ ______________________________________________
Signature of Health Care Provider
Printed Name of Person Completing Form
If you have any concerns about the above information or do not want your child to
receive this medication/treatment; notify the DJJ facility at the phone number indicated.
Phone Number:
Person to Contact:
TO THE PARENT/GUARDIAN: IF THIS BOX IS CHECKED, THIS MEANS THAT YOU HAVE BEEN
NOTIFIED BY PHONE OF THE HEALTH CARE TREATMENT ABOVE. WE NEED YOU TO GIVE
YOUR CONSENT IN WRITING AND SEND THIS FORM BACK TO US AT THE FACILITY ADDRESS
LISTED ABOVE. YOUR SIGNATURE INDICATES THAT YOU GIVE YOUR PERMISSION FOR US
TO ADMINISTER THIS MEDICATION.
_____________________________________
_____________________________________________
Parent/Guardian Signature
Date
** Copy of Notification to be filed in Individual Health Care Record.
Reset/Clear Form
Save As
Print Form
021
FORM
P
1
1
AGE
OF
63M-2
REV. 1-2014
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PARENTAL NOTIFICATION OF
HEALTH-RELATED CARE: MEDICATION MANAGEMENT
(Not for Psychotropic Medications)
N
Y
: ______________________________ D
B
: ____________
AME OF
OUTH
ATE OF
IRTH
F
N
: _______________________ DJJID#: __________ D
: __________
ACILITY
AME
ATE
P
/
:
ARENT
GUARDIAN NAME AND ADDRESS
DJJ F
: __________________________________________________________
ACILITY NAME AND ADDRESS
_____________________________________________________________________________________
Dear
:
Our records indicate that you are the parent(s) or guardian who has authority over health care for the above
named youth. The purpose of this form is to notify you that a licensed health care practitioner has
recommended the following medication or medication changes.
The following medication has been ordered, started or changed:
Medication: _________________________________
_____times per day, by _________for _____days
(route)
Purpose: ______________________________________________________________________________
Possible Side Effects:_____________________________________________________________________
_______________________________________________ ______________________________________________
Signature of Health Care Provider
Printed Name of Person Completing Form
If you have any concerns about the above information or do not want your child to
receive this medication/treatment; notify the DJJ facility at the phone number indicated.
Phone Number:
Person to Contact:
TO THE PARENT/GUARDIAN: IF THIS BOX IS CHECKED, THIS MEANS THAT YOU HAVE BEEN
NOTIFIED BY PHONE OF THE HEALTH CARE TREATMENT ABOVE. WE NEED YOU TO GIVE
YOUR CONSENT IN WRITING AND SEND THIS FORM BACK TO US AT THE FACILITY ADDRESS
LISTED ABOVE. YOUR SIGNATURE INDICATES THAT YOU GIVE YOUR PERMISSION FOR US
TO ADMINISTER THIS MEDICATION.
_____________________________________
_____________________________________________
Parent/Guardian Signature
Date
** Copy of Notification to be filed in Individual Health Care Record.
Reset/Clear Form
Save As
Print Form
021
FORM
P
1
1
AGE
OF
63M-2
REV. 1-2014