Child's details

  • Child's date of birth

Medication and witness details

  • Name of medication

  • Medication expired?


  • Staff administering medication is using correct dosage

  • Medication is being given to the correct child?

  • Full name and signature of witness

  • Witness and Staff administered must be different

Details of medication administered

  • Dosage administered (e.g. 1/2 of a 10mg tablet OR 4 puffs of Ventolin inhaler)

  • Date and time of administration

  • Method of administration

  • Please specify

  • Date and time of last administration

  • Date and time to be administered, or circumstances under which, the medication should be next administered)

  • Full name and signature of staff adminstering the medication

  • Witness and Staff administering must be different

Parent acknowledgement

  • Full name and signature of parent

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