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 #:
Date
Date
Date
Date
Date
Date
Date
Date
Date
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)
Diphenhydramine (Benadryl)
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signature
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signature
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