The following forms are required to be completed in accordance the New Hampshire Administrative Rule, He-M 1201 for the administration of medications in Developmental Services Programs.
He-M 1201 A Form (1 page) is to be completed two times per year pursuant to He-M 1201.10. The Nurse Trainer of each provider agency shall complete a separate Form 1201-A for each certified setting, as applicable, in which authorized providers administer medications.
He-M 1201 A Form Instructions (5 pages) explain how to complete the above He-M 1201 A form.
He-M 1201 A Short Form (1 page) is for programs without reportable errors. Please use this form for all programs without reportable errors.
He-M 1201 B Form (1 page) Is to be completed and sent to the Medication Committee by each Area Agency two times per year pursuant to He-M 1201.10. The form is designed to generate summary statements regarding each provider agency's performance in medication administration in a particular region. The information entered onto the form will be generated through compilation of all the Form 1201-A's submitted to an Area Agency by a particular provider agency. This form is also required of the Area Agencies that do not have subcontract/provider agencies and provide services directly. In such cases, the summary statements will be directly applicable to the Area Agency as the provider organization.
He-M 1201 B Form Instructions (1 page) explain how to complete the above He-M 1201 B form.
References:
NH Administrative Rule, He-M 1201-Administration of Medication
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