Maryland child care programs use this form, without OCC 1216, when a child has a seizure, convulsion or epilepsy disorder and may need medication. The health care provider completes page 1 with the child's seizure types, triggers, emergency protocol, care after a seizure and the medication order, and staff follow it for up to one year.
The authorized health care provider completes and signs page 1. The parent completes the authorization and emergency contacts on page 2, and child care staff complete the checklist, including any staff training, and the administration record.
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Seizure/Convulsion/Epilepsy Disorder Medication Administration Authorization Form
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No. OCC 1216C states it is for seizure, convulsion and epilepsy medication only and is used without OCC 1216. It includes the seizure plan, prescriber's authorization, parent consent, emergency contacts and a log of each dose with the reason it was given.
The authorization may not exceed one year. The provider dates the plan, and at the end of the authorized period the parent's section says an authorized individual must pick up the medication or it will be discarded.
Besides medication, the provider can note special considerations and precautions for activities, sports and trips, describe the help the child needs after a seizure, and say when the child can return to care or resume regular activity.