For a child who needs asthma medication in Maryland child care, this combined form serves as both the asthma action plan and the medication order, so OCC 1216 is not needed. The health care provider sets out severity, triggers and green, exercise, yellow and red zone medicines and actions, and the program follows it for up to one year.
The health care provider completes Section I, the asthma action plan, and Section II, the prescriber's authorization. The parent completes Section III, and child care staff complete Section IV and the medication log.
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Asthma Action Plan and Medication Administration Authorization Form
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No. OCC 1216A states it is for asthma medication only and is used without OCC 1216. It combines the asthma action plan with the prescriber's authorization, parent consent and a staff checklist, plus a page for logging each dose.
The exercise zone lists medication to give prior to all exercise or sports, or when the child feels they need it, with name and strength, dose, route, timing and special instructions. The provider can also check call 911, call parent or another action.
The authorization may not exceed one year, and the provider enters from and to dates. A new form is needed when that period ends, and the parent's section notes that leftover medication must be picked up or it will be discarded.