Medication Authorization And Log (Page 2 of 2) in pdf

Medication Authorization And Log Page 2

To Be Completed By UCP Employee:

Date: ____________________________

Time:

Medication Name:

Dosage:

Comments or Notes:

Signature of UCP Employee: _____________________________________ ______

Date: ______________________

Reviewed by: _________________________________________________________

Date: ______________________

(Signature of parent/guardian)

Upon completing this form, UCP Employee’s must submit this log with their paper time sheet by the 3

and 18

of every month.

Please note:



A separate form must be used for each day medication is administered.



Only medication listed on the reverse side can be administered, this includes over the counter

medications.



UCP employees will not administer any medication without written authorization, specific

instructions and if the medication is not in it’s original packaging unless they have a UCP

supervisors approval.

Please review UCP’s Medication Authorization Policy for more details.

Please see reverse side

Medication Authorization And Log Page 2