Sample Forms
* Before providing medication in child care, contact a local Child Care Health Consultant (CCHC) for training and technical assistance on proper administration. Please refrain from using the forms and plan below until you have been trained by a CCHC.
Sample Parental Notifications
Notification that Facility working with a Child Care Health Consultant
Communicable Disease
- Sample confirmation by health care provider that child with symptoms of an illness can return to group care (Updated 1/26/23)
- Sample notification of exposure to communicable disease (See Communicable Diseases and Exclusion from Child Care chart.)
Medication Administration Forms | Formularios de Administración de Medicamentos
- Medication Administration Checklist | Lista de Verificación para Administrar Medicamentos
- Medication Administration Permission and Record | Formulario de Permiso para la Administración de Medicamentos
- Medication Administration Permission – topical ointments, etc | Formulario de Autorización para la Administración de Medicamentos de Uso Tópico sin Receta, etc.
- Medication Administration Error Report | Informe de Errores con Medicamentos
Medical Action Plans | Planes de Acción Médica
- Allergy and Anaphylaxis (non-food)
- Allergy and Anaphylaxis (food) | Plan de Atención de Emergencias de Alergias Alimentarias y Anafilaxia
- Medical Action Plan: Asthma | Plan de Acción Médico: Asma
- Child Care Diabetes Medical Management Plan
- Medical Action Plan: General | Plan de Acción Médico del Niño
- Seizure Action Plan | Plan de Acción para Crisis Epilépticas