
Additional CDS personnel may be designated at the discretion of the CDS Program Director. Date DATE Signature of Sponsor SIGNATURE OF PROGRAM DIRECTOR REVERSE OF DA FORM 5225-R JUL 1989. CHILD DEVELOPMENT SERVICES CDS MEDICAL DISPENSATION RECORD MONTH For use of this form see AR 608-10 the proponent agency is DCSPER. SEE REVERSE FOR PRIVACY ACT STATEMENT NAME OF CHILD MEDICATION ACTIVITY ROOM NAME OF SPONSOR HOME PHONE AUTHORIZING PHYSICIAN INCLU.
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How to fill out the DA Form 5225 R online
This guide provides clear and comprehensive instructions for filling out the DA Form 5225 R, which is used for authorizing medical dispensation for children in child development services. By following this guide, users can successfully complete the form online with confidence.
Follow the steps to complete the DA Form 5225 R online.
- Press the ‘Get Form’ button to acquire the DA Form 5225 R and open it in your preferred editor.
- Begin by entering the name of the child in the designated field at the top of the form.
- In the 'Medication' section, specify the name of the medication that the child will be receiving.
- Next, fill in the 'Activity Room' name where the child will take their medication.
- Input the complete name of the sponsor responsible for authorizing the medication.
- Indicate the inclusive dates during which the medication will be administered.
- Provide the home phone number of the sponsor for contact purposes.
- Enter the name of the authorizing physician and the medical facility responsible for prescribing the medication.
- Specify the dosage of the medication as directed by the physician.
- Include any specific instructions regarding refrigeration if needed, checking 'Yes' or 'No' as appropriate.
- Fill in the time the medication is to be taken, clearly indicating both the beginning and finishing times.
- Provide a duty phone number for additional contact information.
- Ensure that the CDS personnel dispensing medicine can record the time of administration and initial each time block appropriately.
- Review all entries for accuracy before completing the form.
- Upon finalizing your entries, save the document to ensure your information is retained.
- Finally, download, print, or share the completed form as necessary.
Complete the DA Form 5225 R online today to ensure your child's medication is administered properly.
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