Authorization to Assist with the Self-Administration of Medication 

This certifies that 
__________________________________________ 
(Employee Name) 
Is authorized to Assist with the Self-Administration of Medication  
without direct supervision 
 
Declaration: 
By issuing this voucher, I confirm that the above named individual has completed all required components in accordance with Delaware Policies and Procedural Guidelines.  I understand that by issuing this voucher on behalf of my Agency, I am responsible for ensuring compliance with the aforementioned Policies & Guidelines of the Delaware Assistance with Medication Program. 
 
________________________ 
Date of Class 
 
__________________________________ 
Date Medication Passes Completed 
 

ISSUED BY 

___________________________________ 
AGENCY NAME AND ADDRESS 
___________________________________ 
AGENCY DESIGNEE