Form JGCD-15 Empowering Dreams for the Future CONTROLLED SUBSTANCES INVENTORY FORM School: Medication: Dose: Student’s Name: Column A Column C Column D Column E Column F Column B NUMBER OF TOTAL NUMBER NUMBER TOTAL NUMBER OF PILLS AT GIVEN/USED WASTED NUMBER PILLS (Column A+B) PILLS RECEIVED FORM JGCD-3 ENTER CODE: REMAINING SCHOOL NURSE LAST COUNT DATE TIME (Medication D-Dropped On IN BOTTLE SIGNATURE Administration Floor FORM JGCD-4 Record) V-Student (Enter Here and (Last Entry In (Controlled Vomited in Column F) Substances: Medication Column A) Quantity Received)
Form JGCD-15 Empowering Dreams for the Future CONTROLLED SUBSTANCES INVENTORY FORM School: Student’s Name: Medication: Dose: Column A Column B Column C Column D Column E Column F DATE TIME NUMBER OF PILLS AT LAST COUNT (Last Entry In Column F) NUMBER OF PILLS RECEIVED FORM JGCD-4 (Controlled Substances: Quantity Received) TOTAL (Column A+B) NUMBER GIVEN/USED FORM JGCD-3 (Medication Administration Record) NUMBER WASTED ENTER CODE: D-Dropped On Floor V-Student Vomited Medication TOTAL NUMBER PILLS REMAINING IN BOTTLE (Enter Here and in Column A) SCHOOL NURSE SIGNATURE