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He-M 1201 Forms A, B and C

The following forms are required to be completed in accordance the NH Administrative Rule He-M 1201 Adobe Acrobat Reader Symbol Administration of Medications in Developmental Services Programs.

He-M 1201 A

The He-M 1201 A form is to be completed two times per year pursuant to He-M 1201.11. 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.

The He-M 1201 A Short form is for programs without reportable errors. Please use this form for all programs without reportable errors.

He-M 1201 B

The He-M 1201 B form is to be completed and sent to the Medication Committee by each provider agency two times per year pursuant to He-M 1201.11. The form is designed to generate summary statements regarding each provider agency's oversight of medication administration and healthcare advocacy. The information entered onto the form will be generated through compilation of all the Form 1201-A's submitted by the Nurse Trainer.

He-M 1201-C

The He-M 1201-C form is to be completed and sent to the Medication Committee by each area agency two times per year pursuant to He-M 1201.11. The form is designed to generate summary statements regarding each area agency’s oversight of medication administration and healthcare advocacy in a particular region. The information entered onto the form will be generated through compilation of all the Form 1201-B's submitted.


Adobe Acrobat Reader Symbol Adobe Acrobat Reader format. You can download a free reader from Adobe.

 
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New Hampshire Department of Health and Human Services
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