Daily Log Of Controlled Medications Administered
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1Daily Log of Controlled Medications Administered
Use one Sheet for Each Child
School/Childcare Program__________________________________
Child’s Name _________________________Birth Date _______________Classroom______________
Medication____________________________Dosage___________________Route________________
Time of day medication is to be given_____________________________________________________
Length of time medication is to be given:_________ Start Date ____________End Date____________
Special Instructions___________________________________________________________________
Name of Health Care Provider Prescribing Medication _______________________Phone___________
*All medication received must be counted and signed by staff member as well as guardian.
Date
# of Pills Received
Time of
# of Pills
Initials
Comments
Date & Initial
administration
Remaining
(Staff & Guardian)
Signature
Initials
Date
Staff Signature
Initials
Date
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Parent category: Medical