Form DPP-106H "Medication Administration Form" - Kentucky

What Is Form DPP-106H?

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

Form Details:

  • Released on November 1, 2011;
  • The latest edition provided by the Kentucky Department for Community Based Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DPP-106H by clicking the link below or browse more documents and templates provided by the Kentucky Department for Community Based Services.

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Download Form DPP-106H "Medication Administration Form" - Kentucky

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DPP-106H
Commonwealth of Kentucky
(R. 11/11)
Cabinet for Health and Family Services
Page 1 of 2
Department for Community Based Services
Medication Administration Form
For _____________________(
of_________(
)
MONTH)
YEAR
Child's Name: ________________________________ DOB:_________ Height:_______ Weight: _______ Med. Allergy/
Reaction_______________
Medication
Day (initial the box as medication is given)
1
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Details
Given
Medication:
Dose:
For:
Refill Date:
Medication
Day (initial the box as medication is given)
2
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Details
Given
Medication:
Dose:
For:
Refill Date:
Medication
Day (initial the box as medication is given)
3
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Details
Given
Medication:
Dose:
For:
Refill Date:
Your Initials = Med Taken
Your Initials + R=Med refused
Your Initials + M= Med Missed
File: Original in Passport;
OVER
Copy in Professional Section
* Document on a separate page and notify physician and family social services worker that day.
DPP-106H
Commonwealth of Kentucky
(R. 11/11)
Cabinet for Health and Family Services
Page 1 of 2
Department for Community Based Services
Medication Administration Form
For _____________________(
of_________(
)
MONTH)
YEAR
Child's Name: ________________________________ DOB:_________ Height:_______ Weight: _______ Med. Allergy/
Reaction_______________
Medication
Day (initial the box as medication is given)
1
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Details
Given
Medication:
Dose:
For:
Refill Date:
Medication
Day (initial the box as medication is given)
2
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Details
Given
Medication:
Dose:
For:
Refill Date:
Medication
Day (initial the box as medication is given)
3
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Details
Given
Medication:
Dose:
For:
Refill Date:
Your Initials = Med Taken
Your Initials + R=Med refused
Your Initials + M= Med Missed
File: Original in Passport;
OVER
Copy in Professional Section
* Document on a separate page and notify physician and family social services worker that day.
Page of 2