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:
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Date Given |
Time |
Dosage Given |
Signature of Employee Administering Medication and Title/Position |
Comments |
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UPLOAD FORM