Student Medication Logs Template Page 2
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1
2
3STUDENT
PICTURE
STUDENTS
09.2241 AP.22
HERE
(C
)
ONTINUED
Student Medication Logs
S
M
A
R
TUDENT
EDICATION
DMINISTRATION
ECORD
S
Y
: _____________________________________
CHOOL
EAR
N
S
: _______________________________________ D
B
: ____________ G
: ____________ G
: __________
AME OF
TUDENT
ATE OF
IRTH
ENDER
RADE
A
: __________________________________ N
D
M
: ______________________________________________
LLERGIES
AME AND
OSE OF
EDICATION
R
: _____________ T
(
) G
S
: ___________________ P
S
E
: ____________________________________
OUTE
IME
S
IVEN AT
CHOOL
OSSIBLE
IDE
FFECTS
Classroom teacher when medication is due: _________________ Health Care Provider Name/Phone #: _______________________________________
Emergency Contact Names/Phone #s: _________________________________________________________________________________________
DIRECTIONS: Initial administration or use codes below. A complete signature and initials of each person administrating medication should be included below.
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9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Documentation Codes:
Authorized person(s) administering or counting
medication: Signature/Initials
(A) Absent
(R) Refused*
(W) Dosage withheld*
(E) Early dismissal
________________________________/_________
(F) Field trip
(X) No school
(N) No medication available* (S) Self-administered
________________________________/_________
*Documentation required in student’s health file and parent/guardian to be contacted. Please notify
________________________________/_________
teachers if medication is withheld for any reason. Documentation of medication count is on the back of
________________________________/_________
this form.
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Parent category: Medical