Daily Medication Log
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1Student Procedure
DAILY MEDICATION LOG
09.2241
STUDENTS NAME
GRADE
SCHOOL _______________________________
PHYSICIAN
PHONE NUMBER ______________________________________
ALLERGIES (LIST)_________________________________________________________________________________________________
Medication____________
Dose ________________
Time to be given _______
As needed Med_____
(check)
Initials
Medication____________
Dose ________________
Time to be given _______
As needed Med_____
(check)
Initials
Medication____________
Dose ________________
Time to be given _______
As needed Med_____
(check)
Initials
Medication____________
Dose ________________
Time to be given _______
As needed Med_____
(check)
Initials
Staff Signatures/Initials
____________________________________________/________
_____________________________________________/_______
____________________________________________/________
_____________________________________________/_______
____________________________________________/________
_____________________________________________/_______
* Each school must use this form or similar form that includes the same information.
Reviewed by Board - July 21, 2005
Page 7 of 7
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Parent category: Medical