Medication Administration Log
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1Student: ___________________________________________
Medication / Dosage: ____________________________________________
Administration Time: _____________________
School Year: ___________________
MEDICATION ADMINISTRATION LOG
** One log per student / One log per medication
Please place in Health Insert when completed.
MONTH
WEEK ONE
WEEK TWO
WEEK THREE
WEEK FOUR
WEEK FIVE
M
T
W
T
F
M
T
W
T
F
M
T
W
T
F
M
T
W
T
F
M
T
W
T
F
YEAR
August
September
October
November
December
January
February
March
April
May
June
July
Comments:
Medication Count Log
Date
Count Received
: _______________________
Parent/Guardian
Diagnosis: ________________________________________
CODES
INITIALS
Signature
Address: _______________________________________
____Oral ____Topical ____Inhale ____Other_______
____Oral ____Topical ____Inhale ____Other_______
A Absent
___________
_____________
Phone (home): ___________________(work)_________
Side Effects: _____________________________________
H Holiday
___________
_____________
School: ________________Grade: _________Rm: _____
Physician: _________________Phone:_______________
N No Meds
___________
_____________
Teacher: _________________________________________
R Refused
___________
_____________
Please note time / initial in date blocks when medication is administered. Notify nurse of concerns and / or changes.
Please note time / initial in date blocks when medication is administered. Notify nurse of concerns and / or changes.
Utah County Health Department Form 4/00 LH
Utah County Health Department Form 4/00 LH
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