Medication Administration Record - Jefferson County Public Schools
Medication Administration Record - Jefferson County Public Schools
Medication Administration Record - Jefferson County Public Schools
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>Jefferson</strong> <strong>County</strong> <strong>Public</strong> <strong>Schools</strong><br />
<strong>Medication</strong> <strong>Administration</strong> <strong>Record</strong> (MAR)<br />
2013-2014 School Year<br />
Start Date Stop Date: Time <strong>Medication</strong> Is To Be Given:<br />
Name: JCPS # Medicaid # <strong>Medication</strong> and Description<br />
D.O.B.<br />
Grade: Teacher: Dosage: Frequency: Route:<br />
/ /<br />
Primary Care Provider Name and Telephone:<br />
Special Instructions/Comments:<br />
Parent/Guardian:<br />
Allergies:<br />
Telephone: (H)___________________(W)__________________________<br />
Cell/Pager:______________________Emer:_________________________<br />
Week of Mon. Tues. Wed. Thur. Friday Week of Mon. Tues. Wed. Thur. Friday<br />
08/19/13 01/27/14<br />
08/26/13 02/03/14<br />
09/02/13 02/10/14<br />
09/09/13 02/17/14<br />
09/16/13 02/24/14<br />
09/23/13 03/03/14<br />
09/30/14 03/10/14<br />
10/07/13 03/17/14<br />
10/14/13 03/24/14<br />
10/21/13 03/31/14<br />
10/28/13 04/07/14<br />
11/04/13 04/14/14<br />
11/11/13 04/21/14<br />
11/18/13 04/28/14<br />
11/25/13 05/05/14<br />
12/02/13 05/12/14<br />
12/09/13 05/19/14<br />
12/16/13 05/26/14<br />
12/23/13 06/02/14<br />
12/30/13 06/09/14<br />
01/06/14 06/16/14<br />
01/13/14 06/23/14<br />
01/20/14 06/30/14<br />
INSTRUCTIONS: Each individual administering medication shall sign his/her legal signature below as an identifier for their<br />
initials. Initials shall be filled in above in each block on the appropriate day to be given. If a medication is not given, use one of<br />
the following codes and always notify the parent/guardian that medication is not given. If the parent/guardian brings in<br />
medication record number of pills counted on back of MAR and both people initial. If sent in a sealed envelope, two (2) trained<br />
JCPS staff member must count and record on back of MAR and both people initial. Log field-trip week-end dates on back of MAR.<br />
X = No School A = Absent E = Expired I = Incomplete* M = Missed* N = No <strong>Medication</strong>* R = Refused*<br />
<strong>Medication</strong>*<br />
Upon stopping medication, write the discontinued date here:_____________________<br />
Initials _______Signature________________________<br />
Initials _______Signature________________________<br />
Initials______ Signature__________________________<br />
Initials______ Signature__________________________
ADDITIONAL CHARTING<br />
The number of medications when medication brought in, when calls made to parent/guardian about any<br />
medication or when medication disposition form is sent home, additional initials/signatures of trained staff, &<br />
week-end fieldtrips dates<br />
Date Comments Initials/Signatures<br />
Revision 03/25/13
Change language