Medicine Administration Policy and Procedure

Andri Nicolaou
Child protection Designated Lead

Appendix 1

Medicine Administration form

Request for medication to be administered to a child in school

Child’s Name _________________________

Medication to be Administered _________________________

Expiry date of medicine _________________________

Under what circumstances, (as per doctor’s instructions on the container or in specificcircumstances _________________________
____________________________________________________________________

Level of dosage _________________________

Frequency of dosage _________________________

I confirm that the medication supplied is in its original container and request that it is given to the child named, as per instructions above.

Signed _________________________ (Parent or carer of the child)

Print Name: _________________________

Dated ________________