Student: __________________________________________ DOB: __________ Medication: ___________________________________ Dose: ___________ Time: _______________________ Medication sign out for school activities Date Medication Staff Signature Health Room Date Medication Staff Signature IN Health Room count- Medication count- OUT OUT Staff Signature Signature IN OUT Returned Return OUT
Student: __________________________________________ DOB: __________ Medication: ___________________________________ Dose: ___________ Time: _______________________ Medication sign out for school activities Date OUT Medication count- OUT Staff Signature OUT Health Room Staff Signature OUT Date Medication Returned Medication count- Return Staff Signature IN Health Room Signature IN
2015-2016%20med%20administration%20record-%20final.docx