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315

Appendix V - Medication Administration Record Form 315-5

Procedures

Medication Administration Record

 

 

Student’s Name:  __________________________     Age: ______   Grade:  ______

 

Medication: _________________________________________________________

 

Date Medication Delivered:  ___________                          Quantity:  __________ 

 

Administration Time:              __________________

(as per instructions)                __________________

                                                 __________________

 

 

Parent Signature:  ______________________________________________

 

Principal Signature: _____________________________________________               

 

 

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MEDICATION ADMINISTRATION RECORD

DATE

DOSAGE

TIME ADMINISTERED

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                               

                                                                                                                               

                                                                                               

Administrative Procedure 315 - Form 315-5

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October 2009