Student: ___________________________________________

Medication / Dosage: ____________________________________________

MEDICATION ADMINISTRATION LOG

** One log per student / One log per medication

MONTH
YEAR

WEEK ONE
M

T

W

T

Administration Time: _____________________

WEEK TWO
F

M

T

W

T

Please place in Health Insert when completed.

WEEK THREE
F

M

T

W

T

School Year: ___________________

WEEK FOUR
F

M

T

W

T

WEEK FIVE
F

M

T

W

T

August
September
October
November
December
January
February
March
April
May
June
July
Comments:

Medication Count Log
Date
Count Received
Parent/Guardian:

_______________________

Address: _______________________________________
Phone (home): ___________________(work)_________
School: ________________Grade: _________Rm: _____
Teacher: _________________________________________

Diagnosis: ________________________________________

CODES

INITIALS

Signature

____Oral ____Topical ____Inhale ____Other_______
Side Effects: _____________________________________
Physician: _________________Phone:_______________

A Absent
H Holiday
N No Meds
R Refused

___________
___________
___________
___________

_____________
_____________
_____________
_____________

Please note time / initial in date blocks when medication is administered. Notify nurse of concerns and / or changes.
Utah County Health Department Form 4/00 LH

F

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