FORM 6010 - Non-Medication Consent Form

OCFS-6010

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

NON-MEDICATION CONSENT FORM

This form may be used when a guardian 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.

NOTE: 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 guardian's instructions differ from the instructions on the product's packaging, permission must be received from a health care provider or licensed authorized prescriber.
GUARDIAN TO COMPLETE THIS SECTION (#1 - #14)
1. Child's first and last name*
2. Date of birth*

MonthDayYear
Date
3. Child's known allergies*
4. Name of product (including strength)- BRAND SPECIFIC!*
5. Amount to be administered (ie. dime size amt)*
6. Route of administration (How is it applied to child):*
7A. Frequency to be administered include times of day if appropriate (how often is it applied):*
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)Other
8B: Additional side effects (if Other selected above):
9. What action should the child care provider take if side effects are noted*

Contact parent/guardianOther
If Other, please describe:
10A. Special instructions:*

See package insert for complete list of special instructions (family must supply)Other
10B. Additional special instructions (if Other was selected above):
11. Reason(s) for use (unless confidential by law):*
12. Parent/Guardian name (please print)*
13. Date authorized*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

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