Medication Administration Form

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Updated 04/13
ROBINSON I.S.D.
MEDICATION ADMINISTRATION FORM
Prescription and/or Over-the-counter
***ONE MEDICATION PER PAGE***
Student Name: ______________________________________ Grade : _____ Teacher: __________________ D. O. B. : __________
Medication Name: ______________________________ Dose: _____________ Times to be given: __________________
Reason for medication: _______________________________________________________________________________________
Prescription # _____________ Pharmacy Name ____________________________ Pharmacy Phone Number __________________
Prescribing MD ________________________________________ Prescribing MD Phone Number _____________________________
An adult MUST PICK UP the medication at the end of the year? Initials _____
Dates to be given: _______ to _______
**If medications is a partial dose (1/2 tablet), please make sure ALL medication is cut in half before giving to school**
Parent/Guardian Signature: _____________________________ Phone: ____________________ Date: ______________
ABOVE SECTION FOR PARENTS TO COMPLETE. BOTTOM SECTION FOR SCHOOL STAFF ONLY.
Number of Pills Added: _________ Date: _________Initials _____ Number of Pills Added: ___________ Date: ________Initials ____
Number of Pills Added: _________ Date: _________Initials _____ Number of Pills Added: ___________ Date: ________Initials ____
Number of Pills Added: _________ Date: _________Initials _____ Number of Pills Added: ___________ Date: ________Initials ____
ADMINISTRATION DATES AND TIMES:
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________
Date: ______________ Time: _________________ Administered By: __________________________________________

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