Medication Administration Daily Log (To be ... - School District 68

Medication Administration Daily Log(To be completed for each medication)School Year:Name of Student: D.O.B.: Sex: Grade/Teacher:Name of School: Name of Dispensing Pharmacy: RX#:Name of Medication: Dosage: Route: Frequency: Times given in school:Directions: Initial with time of administration; a complete signature and initials of each person administering medications should be included below.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31SepOctNovDecJanFebMarAprMayJunNOTE: Person administering medication should initial and sign below.INITIAL SIGNATURE INITIAL SIGNATURE CODES1._______ ______________________ 5._______ ______________________ A) Absent O) No Show2._______ ______________________ 6._______ ______________________ E) Early Dismissal W) Dosage Withheld3._______ ______________________ 7._______ ______________________ F) Field Trip X) No School4._______ ______________________ 8._______ ______________________ N) No Medication Available(holiday, weekend, snow day, etc).Use reverse side for reporting significant information (e.g. observations of medication’s effectiveness, adverse reactions, reason for omission, plan to prevent future “no shows”, etc.)

Date Explanation (with signature) Date Explanation (with signature)

School Name: _________________________________________________________MEDICATION ADMINISTRATION LOGSchool Year: Name of Student: D.O.B.:_____Sex: Grade/Teacher: _________________________________Name of Dispensing Pharmacy:RX#: _________________Name of Medication: _________________ Dosage: Route:Frequency: ____________ Times given in school: ____________________________Directions: Sign with time of administration; a complete signature of each person administering medications must be included below.DATE & TIMEMEDICATION/DOSESPECIALINSTRUCTIONS SIGNATURE COMMENTSThis form is part of the permanent record for students receiving medication during school hours. Fill in the above areas with the date and time the medication is given and the signature of the person administering the medication.

Directions: Sign with time of administration; a complete signature of each person administering medications must be included below.DATE & TIMEMEDICATION/DOSESPECIALINSTRUCTIONS SIGNATURE COMMENTS