5330 F2

MEDICATION ADMINSTRATION DAILY LOG
(To be completed for each medication)	School Year  	

Name of Student 	_	Date of Birth 	

Sex 	

Grade or Homeroom (or) Teacher(s) 	

Name of School_ 	_

Name and Dosage of Medication 	

Route(s) 	

Given in School 	_

Directions: Initial with time of administration; a complete signature and initials of each person administering mediations should be included below.
	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																																

INITIAL (of person administering medication)
SIGNATURE	INITIAL	SIGNATURE	CODES

1. 	_	 	

2. 	_	 	

5. 	_	 	

6. 	_	 	

(A) Absent	(O) No Show
(E)	Early Dismissal	(W) Dosage Withheld
(X) No School (i.e.

3. 	_	 	

4. 	_	 	

7. 	_	 	

8. 	_	 	

     (F) Field Trip

(N) No Medication Available

Holiday, weekend, snow days, etc.)

Use reverse side for reporting significant information (e.g. Observation of medication’s effectiveness, adverse reactions, reason for omission, plan to prevent future “no shows".)