Medication Administration Log
Child’s Name: Date of Birth: Rm.:
Medication: Expiration Date: Time(s):
Amount:: Route: Start Date for Medication: End Date:
Special Instructions:
Name of Health Care Provider Prescribing Medication: Phone:
Parent name: Parent Work #: Parent Home #:
Week of:
Week of:
Mon
Date
Date
Date
Date
Fri
Date
Mon
Date
Tue
Date
Wed
Date
Thu
Date
Fri
Date
A.M.
P.M.
Include Time Medication was Given and Initial If the child is absent, mark box with an “A” ; If the medication was not given, mark box “NG” .
Document reason medication was not given in Comments.
Date & Comments:
Staff Signatures
Initials
Pills Received: (All controlled medications must be counted, e.g., Ritalin) _________________
Signature/Date medication was given to classroom: _______________________________________________________________ (Teacher signs & Date)
Signature/Date medication was given back to parent: _______________________________________________________________(Parent signs & Date)
Elizabeth Wilson
5/20/14
2c
Diphenhydramine (Benadryl)
8/30/18
3.75 ml (3/4 tsp)
Mouth
6/1/17
8/31/17
For hives
Sam Mackey
303-555-4141
Grace Wilson
303-555-4203
Your Signature
Y. S.
Pamela Gordon
P. G.
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signature
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signature
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