Health forms and care plans
The following forms are organized alphabetically. The forms that may be applicable for each health condition are linked below.
Please note that many care plan forms commonly used by healthcare providers do not meet WAC requirements for child care and early learning programs. The purpose of the Care Plan Checklists are to ensure that the care plan you have on file for a child meets WAC 110-300-0250 and 110-300-0300.
Health Care Plans
Allergy Care Plan
- Allergy Care Plan Form (3.2 Mb)
- General Care Plan Checklist (141 Kb)
- Medication Authorization Form (117 Kb)
- Medication Administration Record (60 Kb)
- Food Allergies, Food Intolerance, and Special Diets Tracking Form (70 Kb)
Asthma Care Plan
- Asthma Care Plan Form (511 Kb)
- General Care Plan Checklist (141 Kb)
- Medication Authorization Form (117 Kb)
- Medication Administration Record (60 Kb)
- 3-Day Critical Medication Authorization Form (113 Kb)
Diabetes Care Plan
- Diabetes Care Plan Form (245 Kb)
- Diabetes Care Plan Checklist (142 Kb)
- Medication Authorization Form (117 Kb)
- Medication Administration Record (60 Kb)
- 3-Day Critical Medication Authorization Form (113 Kb)
Food Intolerance Care Plan
- Food Intolerance Care Plan Form (110 Kb)
- General Care Plan Checklist (141 Kb)
- Medication Authorization Form (117 Kb)
- Medication Administration Record (60 Kb)
- Food Allergies, Food Intolerance, and Special Diets Tracking Form (70 Kb)
Individual Care Plan
- Individual Care Plan Form (161 Kb)
- General Care Plan Checklist (141 Kb)
- Medication Authorization Form (117 Kb)
- Medication Administration Record (60 Kb)
- 3-Day Critical Medication Authorization Form (113 Kb)
- Controlled Substance Medication Administration Record (126 Kb)
Seizure Care Plan
- Seizure Care Plan Form (363 Kb)
- Seizure Care Plan Checklist (143 Kb)
- Medication Authorization Form (117 Kb)
- Medication Administration Record (60 Kb)
- 3-Day Critical Medication Authorization Form (113 Kb)
- Controlled Substance Medication Administration Record (126 Kb)
- Seizure Activity Log (124 Kb)
Medication and Care Plan
Medication Forms
These forms are intended to be used for medications that are not a part of a care plan.
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Medication Authorization Form (117 Kb)
Used for medications that will be given by child care or early learning program staff to a child during care.
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Medication Administration Record (60 Kb)
Used to document when medication is given by child care or early learning program staff.
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3-Day Critical Medication Authorization Form (113 Kb)
Used for medications that a child regularly takes at home and is lifesaving. A child care or early learning program must have a 3-day supply of these medications in case of an emergency that requires the child to remind in care past usual hours.
Non-Medication Authorization Forms
Hand Lotion Authorization Form
- የእጅ ቅባት አጠቃቀምን የተመለከት የፈቃድ ቅጽ (አማርኛ / Amharic)
- استمارة تفويض استخدام غسول اليدين (العربية /Arabic)
- Форма разрешения на использование увлажняющего крема/лосьона для рук (Русский / Russian)
- Foomka Oggolaanshaha Boomaatada Gacmaha (af Soomaali / Somali)
- Formulario de Autorización de Crema para Manos (Español / Spanish)
- Форма дозволу використання лосьйону для рук (Українська / Ukrainian)
Hand Sanitizer Authorization Form
- የእጅ ማጽጃን አጠቃቀም የተመለከት የፈቃድ ቅጽ (አማርኛ / Amharic)
- (العربية / Arabic) استمارة ترخيص معقم اليدي
- Форма Разрешения На Использование Антисептика Для РУК (Русский / Russian)
- Foomka Oggolaanshaha Jeermis-reebta Gacmaha (af Soomaali / Somali)
- Formulario de Autorización para el Desinfectante de Manos (Español / Spanish)
- Форма Дозволу Використання Санітайзера Для Рук (Українська / Ukrainian)
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Sunscreen Authorization Form (sunscreen brought from home)
- Foomka Oggolaanshaha Kareemka Qorraxda (Kareemka Qorraxda Oo Laga Keenay Guriga) (af Soomaali / Somali)
- Formulario de Autorización para Protector Solar (Protector Solar Traído desde Casa) (Español / Spanish)
Toothpaste From Home Authorization Form
- የጥርስ ሳሙናን አጠቃቀም የተመለከት የፈቃድ ቅጽ (ከቤት የመጣ የጥርስ ሳሙና) (አማርኛ / Amharic)
- (العربية / Arabic) استمارة تفويض استخدام معجون الأسنان (معجون أسنان تم إحضاره من المنزل)
- Разрешение на использование зубной пасты (Зубная паста, принесенная из дома) (Русский / Russian)
- Foomka Oggolaanshaha Daawada Ilkaha (Daawada ilkaha ee Guriga Laga Keeno) (Af Soomaali / Somali)
- Formulario de Autorización para la Pasta Dental (Pasta de dientes traída de casa) (Español / Spanish)
- Форма дозволу використання зубної пасти (зубна паста, принесена з дому) (Українська / Ukrainian)
Toothpaste Authorization Form (Program-Provided/Bulk Toothpaste)
- የፍሎራይድ የጥርስ ሳሙናን አጠቃቀም የተመለከት የፈቃድ ቅጽ (በፕሮግራሙ የቀረበው/ጅምላ የጥርስ ሳሙና) (አማርኛ / Amharic)
- (العربية / Arabic) استمارة تفويض استخدام معجون الأسنان بالفلورايد (معجون أسنان/ غير معلب مقدم من البرنامج)
- Разрешение на использование зубной пасты с фтором (Зубная паста, предоставляемая для всех детей учреждением) (Русский / Russian)
- Foomka Oggolaanshaha Daawada Ilkaha Faloorayd (Barnaamij-Bixiyay/Daawo Ilko Jumlo) (Af Soomaali / Somali)
- Formulario de Autorización para la Pasta Dental con Flúor (Pasta dental a granel/proporcionada por el programa) (Español / Spanish)
- Орма дозволу використання зубної пасти з фтором (Зубна паста, що надається програмою/масового використання) (Українська / Ukrainian)