Student Medication Log
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1Miami-Dade County Public Schools
Clear Form
Division of Student Services, Comprehensive Health Services
STUDENT MEDICATION LOG
School: _____________________
Current School Year: ___________
Student’s name:
Diagnosis:
Date of Birth:
Gr./Teacher/Rm. #:
Medication: _____________________
Dose: ___________ Time: __________
Route: __________________
Parent/Guardian’s Phone Number(s):
Allergies:
Side Effects:
Address:
Medication Administration(
)
see example below
Date
Dose
Route
Time
Initials
(Code)
/Comments
refer to code table below
A.B.C.
10/12/11
1 tablet Oral
11:30AM
(M) Medication not given because of expired
date, parent notified.
Medication Count
Date/Time
Amount on
Quantity
Quantity
Quantity
Total
Initials of
Initials of
Container
On Hand
Received
Returned
Staff
Parent/Guardian
Signature/Title of Staff Giving Medication
Initials
Medication Codes(write in code section)
A. Absent
N. No School
1.
(Holiday/
Teacher Planning Day)
2.
D. Early Dismissal
O. Out of Med.
E. Emergency
R. Refused
3.
Evacuation
F. Field Trip
V. Vomited
4.
5.
M. Missed Medication
W. Withheld Dose
(must
(must explain in comments
explain in comments section)
section)
FM-7115 Rev. (01-13)
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Parent category: Medical