"Leave/Vacation Medication Form" - Delaware

Leave/Vacation Medication Form is a legal document that was released by the Delaware Health and Social Services - a government authority operating within Delaware.

Form Details:

  • Released on May 4, 2016;
  • The latest edition currently provided by the Delaware Health and Social Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Health and Social Services.

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Download "Leave/Vacation Medication Form" - Delaware

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Department of Health and Social Services
Division of Developmental Disabilities Services
Community Services
LEAVE/VACATION MEDICATION FORM
Name: ________________________________________________ MCI #: _________________________
Date of Departure: ________________ Expected Date of Return: _______________________________ __
Destination: __________________________________________________________________________ __
Traveling alone? (If no, specify with whom)_____________________________________________
__
MEDICATIONS: For each medication and strength specify exactly as on the prescription label.
# of
# of
# of
# of
Name of Medication
Strength
Pills
Pills
Name of Medication
Strength
Pills
Pills
Sent
Ret.
Sent
Ret.
Special medication instructions/comment:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________
Signature of Staff who Prepared Medication of Leave & Date
_________________________________________________________
Signature of Staff who Counted the Medication Upon Return & Date
To whom are medications entrusted?
Name/Relationship
I have received the medications listed above and have no questions regarding their administration. I understand
that I may call the agency staff if any further questions arise.
_________________________________________
___________________________________________
Signature of Person Entrusted with Medication/Date
Signature of Agency Staff Transferring Medication/Date
Department of Health and Social Services
Division of Developmental Disabilities Services
Community Services
LEAVE/VACATION MEDICATION FORM
Name: ________________________________________________ MCI #: _________________________
Date of Departure: ________________ Expected Date of Return: _______________________________ __
Destination: __________________________________________________________________________ __
Traveling alone? (If no, specify with whom)_____________________________________________
__
MEDICATIONS: For each medication and strength specify exactly as on the prescription label.
# of
# of
# of
# of
Name of Medication
Strength
Pills
Pills
Name of Medication
Strength
Pills
Pills
Sent
Ret.
Sent
Ret.
Special medication instructions/comment:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________
Signature of Staff who Prepared Medication of Leave & Date
_________________________________________________________
Signature of Staff who Counted the Medication Upon Return & Date
To whom are medications entrusted?
Name/Relationship
I have received the medications listed above and have no questions regarding their administration. I understand
that I may call the agency staff if any further questions arise.
_________________________________________
___________________________________________
Signature of Person Entrusted with Medication/Date
Signature of Agency Staff Transferring Medication/Date
Instructions for use of Leave/Vacation Medication Form
When to be Completed: Every time a person is expected to receive his/her medication from a person other
than a residential or day program staff who have successfully completed LLAM training (example: a person
leaves the home for a vacation, respite or a visit with his/her family).
Instructions for Completion of Form Prior to Individual’s Departure:
1. Staff person (this includes agency contracted staff and shared living provider) completes the top
section of the form.
2. Staff person (this includes agency contracted staff and shared living provider) completes the first
three (3) columns of the table.
3. Staff person (this includes agency contracted staff and shared living provider) completes the
section re: special medication instructions/comments, if applicable.
4. Staff person (this includes agency contracted staff and shared living provider) signs on the line that
states “staff who prepared medication for leave”.
5. Staff person (this includes agency contracted staff and shared living provider) writes the name and
relationship of the person to whom the medication is being transferred on the line that states “to
whom are medications entrusted”.
6. Staff person (this includes agency contracted staff and shared living provider) reviews the
medication and the information on the Leave/Vacation Medication Form with the receiving person.
7. The person receiving the medication signs and dates on the bottom line of the form attesting to
his/her receipt and understanding of the medications.
Instructions for Completion of Form Upon Individual’s Return:
1. Staff person (this includes agency contracted staff and shared living provider) counts the number of
pills returned and documents in Column 4 of the table and signs the form on the indicated line. It is
preferable that this be done in the presence of the person to whom the medications were entrusted.
Where to File Completed Form:
1. Provider agency staff shall file the completed form with the corresponding month’s MARs.
2. Shared Living providers shall forward the form to the consultative nurse who will then forward to
DDDS HIM.
5/4/16
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