Form OCC1216B "Medication Incident Reporting Form" - Maryland

What Is Form OCC1216B?

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 October 6, 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 OCC1216B by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

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Download Form OCC1216B "Medication Incident Reporting Form" - Maryland

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Maryland State Department of Education
Office of Child Care
Medication Error Incident Report
Facility/Provider Name:
Date:
Address:
Phone:
Child’s Name:
Date of Birth:
M
F
Date Incident Occurred:
Time Noted:
Person Administering Medication:
Prescribing Health Care Provider:
Name of the Medication:
Medication Administration Error
___________________________________________
_____Wrong Child
Dose: ______________________________________
_____Wrong Medicine
Scheduled time: ______________________________
_____Wrong Dose
Route of Administration: _______________________
_____Wrong Route
Purpose: ____________________________________
_____Wrong Time: Time Given____Correct Time____
_____Other(list)_______________________________
Describe the Incident and How it Occurred:
Action Taken
Name of Parent/Guardian Notified:
____________________________________________
Date ___________________ Time:________________
Poison Control Notified:
Yes ___No___N/A____
911 Called: Yes _____No_____ N/A_____
Program Director Notified: Yes___ No___ N/A ____
Date __________________Time:_________________
Person Notified in OCC:
____________________________________________
Date__________________ Time: ________________
General Condition of the child:
OCC Nurse Consultant Notified: Yes____ No_____
Date__________________ Time: _________________
Follow up in 24 hours:
Corrective Action:
Signature of the Person Completing Form & Date
Director Signature & Date (if applicable)
Position: ____________________________________
OCC 1216B 10-06-2015
Maryland State Department of Education
Office of Child Care
Medication Error Incident Report
Facility/Provider Name:
Date:
Address:
Phone:
Child’s Name:
Date of Birth:
M
F
Date Incident Occurred:
Time Noted:
Person Administering Medication:
Prescribing Health Care Provider:
Name of the Medication:
Medication Administration Error
___________________________________________
_____Wrong Child
Dose: ______________________________________
_____Wrong Medicine
Scheduled time: ______________________________
_____Wrong Dose
Route of Administration: _______________________
_____Wrong Route
Purpose: ____________________________________
_____Wrong Time: Time Given____Correct Time____
_____Other(list)_______________________________
Describe the Incident and How it Occurred:
Action Taken
Name of Parent/Guardian Notified:
____________________________________________
Date ___________________ Time:________________
Poison Control Notified:
Yes ___No___N/A____
911 Called: Yes _____No_____ N/A_____
Program Director Notified: Yes___ No___ N/A ____
Date __________________Time:_________________
Person Notified in OCC:
____________________________________________
Date__________________ Time: ________________
General Condition of the child:
OCC Nurse Consultant Notified: Yes____ No_____
Date__________________ Time: _________________
Follow up in 24 hours:
Corrective Action:
Signature of the Person Completing Form & Date
Director Signature & Date (if applicable)
Position: ____________________________________
OCC 1216B 10-06-2015