Maryland State Department of Education
Office of Child Care
ASTHMA ACTION PLAN AND MEDICATION ADMINISTRATION AUTHORIZATION FORM
OCC 1216 A REVISED SEPTEMBER 2022 – all previous editions are obsolete PLEASE TURN OVER – THIS FORM HAS 2 SIDES WITH 4 TOTAL SECTIONS
1. CHILD'S NAME (First Middle Last)
2. DATE OF BIRTH (mm/dd/yyyy) ____/____/______
3. Child’s picture (optional)
Section I. ASTHMA ACTION PLAN – MUST BE COMPLETED BY THE HEATLH CARE PROVIDER
4. ASTHMA SEVERITY: Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent Exercise Induced ☐Peak Flow Best___%
5. ASTHMA TRIGGERS (check all that apply): Colds URI Seasonal Allergies Pollen Exercise ☐Animals Dust Smoke Food Weather Other___________________
6. This authorization is NOT TO EXCEED 1 YEAR FROM_____/_____/_____ TO _____/_____/_____
FOR ASTHMA MEDICATION ONLY – THIS FORM IS USED WITHOUT OCC 1216
7. SCHOOL AGE ONLY: OK to Self-Carry/Self Administer ☐ Yes ☐ No
GREEN ZONE - DOING WELL: Long Term Control Medication- Use Daily At Home unless otherwise indicated
The Child has ALL of these Medication Name & Strength Dose Route Time & Frequency Special Instructions
☐Breathing is good
☐No cough or wheeze
☐Can walk, exercise, & play
☐Can sleep all night
If known, peak flow greater than ______
(80% personal best)
Exercise Zone ☐ CALL 911 ☐ CALL PARENT ☐ OTHER: ____________________
☐Prior to all exercise/sports
☐When the child feels they need it
Medication Name & Strength
Dose
Route
Time & Frequency
Special Instructions
YELLOW ZONE - GETTING WORSE ☐ CALL 911 ☐ CALL PARENT ☐ OTHER:__________________
The Child has ANY of these Medication Name & Strength Dose Route Time & Frequency Special Instructions
☐Some problems breathing
☐Wheezing, noisy breathing
☐Tight chest
☐Cough or cold symptoms
☐Shortness of breath
☐Other:________________________
If known, peak flow between
____ and _____ (50% to 79% personal best)
RED ZONE - MEDICAL ALERT/DANGER ☐ CALL 911 ☐ CALL PARENT ☐ OTHER:____________________
The Child has ANY of these Medication Name & Strength Dose Route Time & Frequency Special Instructions
☐Breathing hard and fast
☐Lips or fingernails are blue
☐Trouble walking or talking
☐Medicine is not helping (15-20 mins?)
☐Other:________________________
If known, peak flow below ______
(0% to 49% personal best)
Maryland State Department of Education
Office of Child Care
ASTHMA ACTION PLAN AND MEDICATION ADMINISTRATION AUTHORIZATION FORM
OCC 1216 A REVISED SEPTEMBER 2022 – all previous editions are obsolete PLEASE TURN OVER – THIS FORM HAS 2 SIDES WITH 4 TOTAL SECTIONS
CHILD'S NAME (First Middle Last)
DATE OF BIRTH (mm/dd/yyyy) ____/____/______
Section II. PRESCRIBER'S AUTHORIZATION – MUST BE COMPLETED BY THE HEALTH CARE PROVIDER
8. PRESCRIBER'S NAME/TITLE
Place Stamp Here
TELEPHONE
FAX
ADDRESS
CITY
STATE
ZIP CODE
9a. PRESCRIBER'S SIGNATURE (Parent/guardian cannot sign here)
(original signature or signature stamp only)
9b. DATE (mm/dd/yyyy)
Section III. PARENT/GUARDIAN AUTHORIZATION – MUST BE COMPLETED BY THE PARENT/GUARDIAN
I authorize the childcare staff to administer the medication or to supervise the child in self-administration as prescribed above. I certify that I have legal authority to consent to medical
treatment for the child named above, including the administration of medication at the facility. I understand that at the end of the authorized period an authorized individual must pick
up the medication; otherwise, it will be discarded. I authorize childcare staff and the authorized prescriber indicated on this form to communicate in compliance with HIPAA. I
understand that per COMAR 13A.15, 13A.16, 13A.17, and 13A.18; the childcare program may revoke the child’s authorization to self-carry/self-administer medication.
School Age Child Only: OK to Self-Carry/Self -Administer Yes No
10a. PARENT/GUARDIAN SIGNATURE
10b. DATE (mm/dd/yyyy)
10c. INDIVIDUALS AUTHORIZED TO PICK UP MEDICATION
10d. CELL PHONE #
10e. HOME PHONE #
10f. WORK PHONE #
Emergency Contact(s)
Name/Relationship
Phone Number to be used in case of Emergency
Parent/Guardian 1
Parent/Guardian 2
Emergency 1
Emergency 2
Section IV. CHILD CARE STAFF USE ONLY – MUST BE COMPLETED BY THE CHILD CARE PROGRAM
Child Care Responsibilities:
1. Medication named above was received Expiration date _________ ☐ Yes ☐ No
2. Medication labeled as required by COMAR ☐ Yes ☐ No
3. OCC 1214 Emergency Form updated ☐ Yes ☐ No
4. OCC 1215 Health Inventory updated ☐ Yes ☐ No
5. Modified Diet/Exercise Plan ☐ Yes ☐ No ☐N/A
6. Individualized Treatment/Care Plan: Medical/Behavioral/IEP/IFSP ☐ Yes ☐ No ☐N/A
7. Staff approved to administer medication is available onsite, field trips ☐ Yes ☐ No
Reviewed by (printed name and signature):
DATE (mm/dd/yyyy)
Maryland State Department of Education
Office of Child Care
ASTHMA ACTION PLAN AND MEDICATION ADMINISTRATION AUTHORIZATION FORM
OCC 1216A REVISED AUGUST 2022 – all previous editions are obsolete
MEDICATION ADMINISTRATION LOG
Each administration of a medication to the child, whether prescription or non-prescription, including self-administration of
medication by a child, shall be noted in the child’s record. Keep this form in the child’s permanent record as required by
COMAR. Print additional copies of this page as needed.
Child’s Name:
Date of Birth:
MEDICATION
DATE
TIME
DOSAGE
ROUTE
REACTIONS OBSERVED (IF ANY)
SIGNATURE
