Form OCC1216A "Seizure Medication Administration Authorization Form" - Maryland

What Is Form OCC1216A?

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

Form Details:

  • Released on August 20, 2015;
  • The latest edition provided by the Maryland State Department of Education;
  • 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 printable version of Form OCC1216A by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download Form OCC1216A "Seizure Medication Administration Authorization Form" - Maryland

380 times
Rate (4.3 / 5) 23 votes
MARYLAND STATE DEPARTMENT OF EDUCATION
OFFICE OF CHILD CARE
Seizure Medication Administration Authorization Form
Name of Child Care Facility ___________________________________________________________________
This form authorizes emergency seizure care for _________________________________________________ ❒ M ❒ F
(Child’s Name)
(Date of Birth)
while attending the above named child care facility during child care hours. This form must be completed by the
child’s physician and signed by both physician and parent.
Treating Physician
______________________________ Phone#____________________ # After Hours_____________
Significant Medical History
: _________________________________________________________________________
Seizure Care Information
Seizure Type
Length
Frequency
Description
Seizure Triggers or Warning Signs: ____________________________________________________________________
Seizure Emergency Protocol (Check all that apply and clarify below)
❒ Call 911 for transport to ____________________________________________❒ Notify parent or emergency contact
❒ Notify treating physician _____________________________❒ Other_______________________________________
❒ Administer emergency medications as indicated below:
Emergency
Dosage Time
Route/method
Side Effects
Special Instructions
Medication
Does child need to leave the classroom after a seizure? ❒ Yes ❒ No If YES, describe process for returning the child to
the classroom. ______________________________________________________________________________________
Special Considerations and Precautions (regarding activities, sports, trips, etc.) __________________________________
________________________________________________________________________________________________________________________
Physician Signature: ____________________________________________________ Date: _______________________
Parent Information & Authorization: Medications must be in the original container and labeled with the child’s name,
name of medication, directions for medication’s administration, and date of the prescription. I request that medication
be administered to my child as described and directed above and attest that I have administered at least one dose of the
medication to my child without adverse effects. I agree to review special instruction and demonstrate the medication
administration procedure to the child care provider. I understand the risk and authorize for administration of
emergency seizure medication to my child.
Parent/Guardian Signature: ______________________________________________ Date: ______________________
OCC 1216A (8/20/15)
MARYLAND STATE DEPARTMENT OF EDUCATION
OFFICE OF CHILD CARE
Seizure Medication Administration Authorization Form
Name of Child Care Facility ___________________________________________________________________
This form authorizes emergency seizure care for _________________________________________________ ❒ M ❒ F
(Child’s Name)
(Date of Birth)
while attending the above named child care facility during child care hours. This form must be completed by the
child’s physician and signed by both physician and parent.
Treating Physician
______________________________ Phone#____________________ # After Hours_____________
Significant Medical History
: _________________________________________________________________________
Seizure Care Information
Seizure Type
Length
Frequency
Description
Seizure Triggers or Warning Signs: ____________________________________________________________________
Seizure Emergency Protocol (Check all that apply and clarify below)
❒ Call 911 for transport to ____________________________________________❒ Notify parent or emergency contact
❒ Notify treating physician _____________________________❒ Other_______________________________________
❒ Administer emergency medications as indicated below:
Emergency
Dosage Time
Route/method
Side Effects
Special Instructions
Medication
Does child need to leave the classroom after a seizure? ❒ Yes ❒ No If YES, describe process for returning the child to
the classroom. ______________________________________________________________________________________
Special Considerations and Precautions (regarding activities, sports, trips, etc.) __________________________________
________________________________________________________________________________________________________________________
Physician Signature: ____________________________________________________ Date: _______________________
Parent Information & Authorization: Medications must be in the original container and labeled with the child’s name,
name of medication, directions for medication’s administration, and date of the prescription. I request that medication
be administered to my child as described and directed above and attest that I have administered at least one dose of the
medication to my child without adverse effects. I agree to review special instruction and demonstrate the medication
administration procedure to the child care provider. I understand the risk and authorize for administration of
emergency seizure medication to my child.
Parent/Guardian Signature: ______________________________________________ Date: ______________________
OCC 1216A (8/20/15)