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507.2E1 Record Of The Administration Of Medication

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:.

 

 

 

 

 

 

 

*********************

 

 

 

 

 

 

Date Given

 

 

 

 Time 

 

 

Dosage Given 

 

 Signature of Employee Administering Medication and Title/Position         

 

 

 

     Comments          

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Approved: March 12, 2007

Reviewed: March 14, 2022

Revised: