California child care facilities licensed by Community Care Licensing, including centers, schools and family child care homes, need LIC 701A before staff give a child gastrostomy-tube feeding or liquid medication through a G-tube. The physician confirms the child's condition is stable enough for trained laypeople, designates who will teach them, and writes step-by-step instructions.
The child's authorized representative signs Part A, the consent and release of information. The physician, physician assistant or nurse practitioner completes Part B, the medical assessment and written instructions, and signs.
Download the current version from the source each time; forms change without notice.
Gastrostomy-Tube Care: Physician's Checklist (Child Care Facilities)
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Each person who gives G-tube care must be instructed by a competent person designated by the child's physician. The physician names that person on LIC 701A, and it may be the child's authorized representative, such as a parent.
At least annually, and whenever the child's needs change, such as a different type of G-tube or a change in the frequency of feeding or the amount or type of formula or liquid medication.