RECORD OF THE ADMINISTRATION OF MEDICATION
Forms are available in all school offices.
Name of Student:
Parents' Phone Number:
Grade:
Medication:
Date to Begin:
Date to End:
Dosage:
Method:
Time:
Prescriber or person authorizing administration:
Phone #1:
Phone #2:
Possible Adverse Reaction:
Person(s) Authorized to Administer Medication:.
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Date Given
Time
Dosage Given
Signature of Employee Administering Medication and Title/Position
Comments
Approved: March 12, 2007
Reviewed: March 14, 2022
Revised: