Student Medication Log Form
Use this form to record details of student medication administration accurately. Please complete all relevant sections for each medication event.
Student Name
*
First Name
Last Name
Student ID (if applicable, do not use sensitive identifiers)
Medication Name
*
Dosage
*
Route of Administration
*
Please Select
Oral
Topical
Inhalation
Injection
Other
Date and Time Administered
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason or Instructions
Administrator Name
*
First Name
Last Name
Administrator Role
*
Please Select
School Nurse
Teacher
Health Assistant
Other
Notes or Follow-up Needed
Submit Log Entry
Should be Empty: