Daily Drug Bag Log
On-coming Provider
*
First Name
Last Name
Off-going Provider
First Name
Last Name
Agency & Unit
*
FMI-Safford Med 1
FMI-Safford Med 2
Greenlee 41
Greenlee 42
Greenlee 43
Greenlee 44
LifeLine 821
LifeLine 822
LifeLine 823
LifeLine 824
PFD 352
PFD 354
Date
*
-
Month
-
Day
Year
Date
Old Seal #
New Seal #
*
All medications have been verified to ensure they are present, not expired, not damaged, and not altered by any other means.
*
Yes
No (explain below)
Action
*
Handoff
Drug Use
Medication Replacement
Other
Notes
Any explanation needed can be placed here
On-coming Provider's Signature
*
Off-going Provider's Signature
Submit
Should be Empty: