Daily Medication Log
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1Plymouth Joint School District
DAILY MEDICATION LOG -- AS NEEDED MEDICATIONS
Name ____________________________________________ Grade _______ School _______________
Medication and Dosage _________________________________________________________________
Frequency and Time __________________ Date Begun _______________ Date to End _____________
Parent/ Guardian Name _________________________________________ Phone _________________
Consent form on file: YES NO
DATE
TIME
DOSAGE
SIGNATURE
DATE
TIME
DOSAGE
SIGNATURE
MEDS RECEIVED:
STAFF DISTRIBUTING MEDS:
Date
Quantity
Initials
Signature
Initials
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
1-16 AN/SS M:Drive/Nursing/Medication Administration/Daily Med Log – as needed
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Parent category: Medical