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 COVID19 symptoms can return to group care (Updated 4/5/22)
• Sample notification of communicable disease (See Communicable Diseases and Exclusion from Child Care chart.)

Medication Administration Forms

• Medication Administration Checklist | Español
• Medication Administration Permission and Record | Español
• Medication Administration Permission – topical ointments, etc | Español
• Medication Administration Error Report | Español

Medical Action Plans

• Allergy and Anaphylaxis (non-food)
• Allergy and Anaphylaxis (food)
• Allergy and Anaphylaxis (food) – Español
• Asthma | Español
• Diabetes
• General | Español
• Seizure
• Seizure – Español

Child Health Assessments

• Children’s Medical Report
• Children’s Medical Report – Español

Staff Health Assessments

• Staff Health Assessment/Medical Report
• Tuberculosis Screening or Test Record