Medication Administration Log
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Student:
Medication/Dosage:
Administration Time:
Medication Administration Log **One log per student/ One log per medication
MONTH
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August September October November December January February March April May June July
Medication Count Log Date Count Received Initials Parent/Guardian: Address: Phone: School: Teacher:
Work:
Diagnosis: Oral Topical Side Effects:
Grade:
Physician: Phone:
Inhale
Other
CODES A ABSENT H HOLIDAY
Please note time and initials in date box when medication is given.
N NO MEDS R REFUSED
Notify School Nurse of changes or concerns.
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Medication/Dosage:
Administration Time:
Medication Administration Log **One log per student/ One log per medication
MONTH
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
August September October November December January February March April May June July
Medication Count Log Date Count Received Initials Parent/Guardian: Address: Phone: School: Teacher:
Work:
Diagnosis: Oral Topical Side Effects:
Grade:
Physician: Phone:
Inhale
Other
CODES A ABSENT H HOLIDAY
Please note time and initials in date box when medication is given.
N NO MEDS R REFUSED
Notify School Nurse of changes or concerns.
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
Name:
Initials:
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