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
- General Care Plan Checklist (141 Kb) – Child Care programs: Use this checklist to confirm that a child’s care plan forms are complete and WAC compliant. The following forms may also be needed:
- Allergy Care Plan Form (3.2 Mb) – Use if a child does not already have an Allergy Care Plan from their healthcare provider.
- Medication Authorization Form (117 Kb) – Use if there is information missing from the care plan for any medication that is prescribed.
- Medication Administration Record (60 Kb) – Use one form per medication to record when it is given.
- Food Allergies, Food Intolerance, and Special Diets Tracking Form (70 Kb) – Used for tracking all students with special dietary needs.
Asthma Care Plan
- General Care Plan Checklist (141 Kb)
Child Care programs: use this checklist to confirm that a child’s care plan forms are complete and WAC compliant. The following forms may also be needed:- Asthma Care Plan Form (511 Kb)
Use if a child does not already have an Asthma Care Plan from their healthcare provider. - Medication Authorization Form (117 Kb)
Use if there is information missing from the care plan for any medication that is prescribed. - Medication Administration Record (60 Kb)
Use one form per medication to record when it is given. - 3-Day Critical Medication Authorization Form (113 Kb)
Use if the child takes a lifesaving medication that is usually given at home, in the event the child needs to remain in child care past their usual hours.
- Asthma Care Plan Form (511 Kb)
Diabetes Care Plan
- Diabetes Care Plan Checklist (142 Kb)
Child Care programs: use this checklist to confirm that a child’s care plan forms are complete and WAC compliant. The following forms may also be needed:- Diabetes Care Plan Form (245 Kb)
Use if a child does not already have a Diabetes Care Plan from their healthcare provider. - Medication Authorization Form (117 Kb)
Use if there is information missing from the care plan for any medication that is prescribed. - Medication Administration Record (60 Kb)
Use one form per medication to record when it is given. - 3-Day Critical Medication Authorization Form (113 Kb)
Use if the child takes a lifesaving medication that is usually given at home, in the event the child needs to remain in child care past their usual hours.
- Diabetes Care Plan Form (245 Kb)
Food Intolerance Care Plan
- General Care Plan Checklist (141 Kb)
Child Care programs use this checklist to confirm that a child’s care plan forms are complete and WAC compliant. The following forms may also be needed:- Food Intolerance Care Plan Form (110 Kb)
Use if a child does not already have a Food Intolerance Care Plan from their healthcare provider. - Medication Authorization Form (117 Kb)
Use if there is information missing from the care plan for any medication that is prescribed. - Medication Administration Record (60 Kb)
Use one form per medication to record when it is given. - Food Allergies, Food Intolerance, and Special Diets Tracking Form (70 Kb)
Use for tracking all students with special dietary needs.
- Food Intolerance Care Plan Form (110 Kb)
Individual Care Plan
- General Care Plan Checklist (141 Kb)
Child Care programs: Use this checklist to confirm that a child’s care plan forms are complete and WAC compliant. The following forms may also be needed:- Individual Care Plan Form (161 Kb)
Use if a child does not already have a care plan from their healthcare provider. - Medication Authorization Form (117 Kb)
Use if there is information missing from the care plan for any medication that is prescribed. - Medication Administration Record (60 Kb)
Use one form per medication to record when it is given. - 3-Day Critical Medication Authorization Form (113 Kb)
Use if the child takes a lifesaving medication that is usually given at home, in the event the child needs to remain in child care past their usual hours. - Controlled Substance Medication Administration Record (126 Kb)
If a child takes a medication that is regulated by the federal government due to potential for abuse, use this form to record when it is given.
- Individual Care Plan Form (161 Kb)
Seizure Care Plan
- Seizure Care Plan Checklist (143 Kb)
Child Care programs: Use this checklist to confirm that a child’s care plan forms are complete and WAC compliant. The following forms may also be needed:- Seizure Care Plan Form (363 Kb)
Use if a child does not already have a seizure care plan from their healthcare provider. - Medication Authorization Form (117 Kb)
Use if there is information missing from the care plan for any medication that is prescribed. - Medication Administration Record (60 Kb)
Use one form per medication to record when it is given. - 3-Day Critical Medication Authorization Form (113 Kb)
Use if the child takes a lifesaving medication that is usually given at home, in the event the child needs to remain in child care past their usual hours. - Controlled Substance Medication Administration Record (126 Kb)
If a child takes a medication that is regulated by the federal government due to potential for abuse, use this form to record when it is given. - Seizure Activity Log (124 Kb)
Use to record important information and observations of a child’s seizures.
- Seizure Care Plan Form (363 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)