Sample Medication Administration Daily Log 
(To be completed for each medication)
School Year __________________________
Name of Student________________________________  Date of Birth ________________  Sex ___  Grade/Home Room (or Teacher) _______________________________________________
Name of School _________________________________________________
Name and Dosage of Medication______________________________________    Route ________    Frequency __________    Time(s) Given in School _____________________

Directions:  Initial with time of administration; a complete signature and initials of each person administrating medications should be included below.

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3031	

Sept	

	

	

	

	

	

	

	

	

	

	

Oct	

	

	

	

	

	

	

	

	

	

	

Nov	

	

	

	

	

	

	

	

	

	

	

Dec	

	

	

	

	

	

	

	

	

	

	

Jan	

	

	

	

	

	

	

	

	

	

	

Feb	

	

	

	

	

	

	

	

	

	

	

Mar	

	

	

	

	

	

	

	

	

	

	

Apr	

	

	

	

	

	

	

	

	

	

	

May	

	

	

	

	

	

	

	

	

	

	

June	

	

	

	

	

	

	

	

	

	

	
INITIAL 	       SIGNATURE	  	  								                        CODES*
(of person administering medication)
			    						
1.  ________    __________________________________                  ______________________________   (A) Absent          (O)  No Show													
2.  ________     __________________________________                   ______________________________   (E) Early Dismissal (W) Dosage Withheld 

3.  ________     __________________________________                   ______________________________   (F) Field Trip      (X) No School (e.g.., holiday, 
                                                               			  weekend, snow day, etc.)
4.  _______      __________________________________                    ______________________________      (N)  No Medication Available 

Use reverse side for reporting significant information (e.g. observations of medication’s effectiveness, adverse reactions, reason for omission, plan to prevent future “no shows”).

Sample Medication Log  cont.
  DATE                      EXPLANATION (with signature)          DATE                                             EXPLANATION (with signature)