ࡱ> ~+ Objbj77 2`c]sdc]sd  )))))===8ul=^&''''TQ `RSTV]X]X]X]X]X]X]$E`b*|]])XS~PTQXSXS|]))''W2]UUUXSF)')'V]UXSV]UU:RZ@Z'?9WSRZ B]]0^ZR%cS%cZZ%c)[@XSXSUXSXSXSXSXS|]|]UXSXSXS^XSXSXSXS%cXSXSXSXSXSXSXSXSXS : 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 parents instructions differ from the instructions on the products 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:  FORMTEXT       Date of birth:  FORMTEXT      Child s known allergies:  FORMTEXT      4. Name of product (including strength):  FORMTEXT      Amount to be administered:  FORMTEXT      Route of administration:  FORMTEXT      7A. Frequency to be administered, include times of day if appropriate:  FORMTEXT       OR7B. Identify the conditions that will necessitate administration of the product (signs and symptoms must be observable prior to administration):  FORMTEXT      8A. Possible side effects:  FORMCHECKBOX  See product label for complete list of possible side effects (parent must supply) AND/OR8B: Additional side effects:  FORMTEXT      9. What action should the child care provider take if side effects are noted:  FORMCHECKBOX  Contact parent  FORMTEXT          IXe|}~  $ ( 8 9 ȿ}ri`XMrXrh2hDI^JaJh.Ta^JaJh2h.TaaJh.Tah.TaaJh2hL.^JaJhJ^JaJh2hH^JaJ hvaJhQhKaJhvchIzCJaJhZ h-:CJhZ hX5^JaJh'haOCJh'h&oCJhaOCJ^Jh` ,5CJ\hH 5CJ\haO5CJ\ h` ,CJ hCJ"Ie}~ 5  X j  (($IfgdZ  & F E$If^`Ex(gdH  & F h^hgdIz & F h<^hgdd<gdIz$a$gdvgdaO$a$gdaO $ ra$gdt rgdt9 :     l q ~  V X d f j ·~u~lfZQHh\5CJaJhJC5CJaJhGJ'h,5CJaJ h-:aJhvh!aJhvhPaJhvh=aJhvhqOhaJ h(aJ hqOhaJhQhqOhaJh h&o5aJh&o^JaJhh&o^JaJhh&o^Jhh&oaJ h&oaJhJh 5aJh2h,aJh2hK^JaJh^JaJj l   $ j  "۽xj\jhGJ'hI1UjthGJ'hI1UhGJ'hI1CJaJ jhGJ'hI1UmHnHujhGJ'hI1U hGJ'hI1jhGJ'hI1UhGJ'hI1CJhGJ'hI15CJaJha5CJaJh15CJaJh2h15CJaJhGJ'h,5CJaJhGJ'h\5CJaJ!j  3kd\$$IfsF>+L H t0+6    44 saytZ  & F E$If^`E (($IfgdZ  & F $If^`"02X^`tvx,.0:<@ǷФݓ~mgݓYmjhGJ'hI1U h!CJ jhGJ'hI1UmHnHujohGJ'hI1U hGJ'hI1jhGJ'hI1U hSdCJ$jhGJ'hI1UaJmHnHujhGJ'hI1UaJhGJ'hI1aJjhGJ'hI1UaJhGJ'hI1CJhGJ'hI1CJaJhGJ'hCJ hCJ ^> & F $If^` & F  $If^` (($IfgdZ $If>@naX $Ifgd' (($Ifgd'kdW$$IfsFb0 >+   t0+6    44 sayti@h(<>j"$&,ߘzqzf^fVfhCJaJhSdCJaJhGJ'hI1CJaJhGJ'hSdCJ hSdCJhGJ'hCJ hCJhGJ'hI1CJjh'UmHnHuh'hH 56^JjhH UmHnHu jhGJ'hH UmHnHujhGJ'hH U hGJ'hH jhGJ'hH U hH CJhGJ'hH CJT (($IfgdZ lkdx$$Ifs>++ t0+644 sayti,.BDFPRTV8`fhtvx򽶽{qg\PEjhZ hI1UhGJ'hI1>*CJaJhGJ'hI156\hGJ'hI16aJhGJ'hI16CJhGJ'hI1CJaJ hCJjh-CJUj$h-CJUjhGJ'hI1CJU h'CJ hGJ'hI1hGJ'hI1CJ$jhGJ'hI1UaJmHnHuj hGJ'hI1UaJhGJ'hI1aJjhGJ'hI1UaJTVhvy x$IfgdYd($IfgdZ lkd$$Ifs>++ t0+644 saytivx !(($IfgdZ lkd$$Ifs>++ t0+644 sayt1z|~4&4(4*4T4V4̾q`^UJjhGJ'hSdUhGJ'h,CJU jhZ hZ UmHnHujhZ hZ U hZ hZ jhZ hZ Ujh-CJUjNh-CJUjhGJ'hI1CJUhGJ'hI1CJjh'UmHnHu hGJ'hI1hGJ'hI156CJ\jhZ hI1Uj;hZ hI1U hZ hI1z(4|4uu !<($Ifgd' (($Ifgd'jkd$$Ifs>++ t0+644 saytZ  Other (describe):  FORMTEXT       10A. Special instructions:  FORMCHECKBOX  See package insert for complete list of special instructions (parent must supply) AND/OR 10B. Additional special instructions:  FORMTEXT       11. Reason(s) for use (unless confidential by law):  FORMTEXT      12. Parent name (please print):  FORMTEXT      13. Date authorized:  FORMTEXT      14. Parent signature: X DAY CARE PROGRAM TO COMPLETE THIS SECTV4j4l4n4x4z4|4~444444444^55555555࿸zofXKhGJ'hI156\]jh'UmHnHuhGJ'hI1CJhGJ'hI1CJaJjh-CJUjO h-CJUjhGJ'hI1CJU h'CJhGJ'hI1CJhGJ'hI1CJaJ hGJ'hI1hGJ'hI1CJaJmHnHu jhGJ'hSdUmHnHujhGJ'hSdUj8 hGJ'hSdU hGJ'hSd|4~44555| $IfgdY $$Ifa$lkd $$Ifs>++ t0+644 sayt155$6&6| $IfgdL: (($IfgdZ lkd $$Ifs>++ t0+644 sayt155666 6"6$6&6(6*6>6D6N6T6V66ꘑ|obUH>1hhI156\]hJ.56\]hh56\]hL:h*K56\]hL:h56\]hL:hI156\]jh'UmHnHu hGJ'hI1 hL:h"hI156CJ\]^J4jhGJ'hI156CJU\]^JmHnHu/jX hGJ'hI156CJU\]^J hGJ'hI156CJ\]^J)jhGJ'hI156CJU\]^J&6(66 (($Ifgd'lkd $$Ifs>++ t0+644 saytZ 6666666667777"7$7&7*7R7T7h7j7l7v7x7|777777캳ses\QhGJ'huFCJaJhGJ'huFaJj hGJ'huFU jhGJ'huFUmHnHuj` hGJ'huFU hGJ'huFjhGJ'huFUhGJ'huFCJ haCJ hGJ'hI1hZ hZ 56\]+jc hZ hI156CJU\]hZ hI156CJ\]%jhZ hI156CJU\]666&7R7z7zz (($IfgdZ $Ifgddlkd $$Ifs>++ t0+644 sayt'z7|7777xmx $IfgdZ $Ifgdd}kdL$$Ifl0>+{6 t0+644 laytZ 77 L x($Ifgd'lkd$$Ifle>++ t0+644 layta778LLL L"L&L0L8LFLHL\L^L`LjLlLnLpLrLvLzLLLLLLLLLLLM MM M"M,M.M0M2M4M8MjMʹ٫ʏʹفʹsjhGJ'huFUjbhGJ'huFUhGJ'huFCJaJ jhGJ'huFUmHnHujhGJ'huFUjhGJ'huFU huFCJhGJ'huFCJ haCJ hGJ'huFh*huFCJaJUhaCJaJhOqhOqCJaJ,ION (#15 - #21)15. Program name:  FORMTEXT       16. Facility ID number:  FORMTEXT      17. Program telephone number:  FORMTEXT       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):  FORMTEXT       20. Date received from parent:  FORMTEXT       21. 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