OCFS-6010 (5/2015)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Non-medication Consent Form

Child Day Care Programs

This form may be used when a parent consents to having over-the-counter products administered to their child in a child day care program. These products include, but are not limited to: topical ointments, lotions and creams, sprays, sunscreen products and topically applied insect repellant.

This form should NOT be used to meet the consent requirements for the administration of the following: prescription medications, oral over-the-counter medications, medicated patches, and eye, ear, or nasal drops or sprays. OCFS Form 7002 would meet the consent requirements for medications.

One form must be completed for each over-the-counter product. Multiple products cannot be listed on one form.

This form must be completed in a language in which the staff is literate.

If parent’s instructions differ from the instructions on the product’s packaging, permission must be received from a health care provider or licensed authorized prescriber.

PARENT TO COMPLETE THIS SECTION (#1 - #14)

Child’s first and last name:

Date of birth:

Child’s known allergies:

4. Name of product (including strength):

Amount to be administered:

Route of administration:

Topical
7A. Frequency to be administered, include times of day if appropriate:

OR
7B. Identify the conditions that will necessitate administration of the product (signs and symptoms must be observable prior to administration):
8A. Possible side effects: See product label for complete list of possible side effects (parent must supply)

AND/OR
8B: Additional side effects:
9. What action should the child care provider take if side effects are noted:

Contact parent

Other (describe):

10A. Special instructions: See package insert for complete list of special instructions (parent must supply)

AND/OR

10B. Additional special instructions:

11. Reason(s) for use (unless confidential by law):
12. Parent name (please print):

13. Date authorized:

14. Parent signature:

X

DAY CARE PROGRAM TO COMPLETE THIS SECTION (#15 - #21)
15. Program name:

Happy Kids Day Care

16. Facility ID number:

40139DCC	17. Program telephone number:

518-732-4569

18. I have verified that #1, -#14 are complete. My signature indicates that all information needed to administer this product has been given to the child day care program.
19. Staff’s name (please print):

Amy L Bielinski

20. Date received from parent:

21. Staff’s signature:

X

2015-04-29