ADAMS TWELVE Five Star Schools
MEDICATION RECORD
School Year 2013 – 2014
Student ID # Signature Print Name Initial
ICD-9 code
A - Absent NS - No School
M - Missed Dose S - Suspended
OM - Out of Medicine FT - Field Trip
ER – Early Release
AUGUST
/SEPTEMBER
/OCTOBER
t / t / t / t / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4t / t / t / t / t / 9 / 10 / 11 / 12 / 13 / 7 / 8 / 9 / 10 / 11
t / t / t / t / t / 16 / 17 / 18 / 19 / 20 / 14 / 15 / 16 / 17 / 18
t / 20 / 21 / 22 / 23 / 23 / 24 / 25 / 26 / 27 / 21 / 22 / 23 / 24 / 25
26 / 27 / 28 / 29 / 30 / 30 / 28 / 29 / 30 / 31
NOVEMBER
/DECEMBER
/JANUARY
1 / 2 / 3 / 4 / 5 / 6 / t / t / t4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 6 / 7 / 8 / 9 / 10
t / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / t / 13 / 14 / 15 / 16 / 17
18 / 19 / 20 / 21 / 22 / t / t / t / t / t / t / 21 / 22 / 23 / 24
25 / 26 / t / t / t / t / t / 27 / 28 / 29 / 30 / 31
FEBRUARY
/MARCH
/APRIL
3 / 4 / 5 / 6 / 7 / 1 / 2 / 3 / 43 / 4 / 5 / 6 / 7 / 10 / 11 / 12 / 13 / 14 / 5 / 6 / 7 / 8 / 9
10 / 11 / 12 / 13 / 14 / 17 / 18 / 19 / 20 / 21 / 14 / 15 / 16 / 17 / 18
t / 18 / 19 / 20 / 21 / t / t / t / t / t / 21 / 22 / 23 / 24 / 25
24 / 25 / 26 / 27 / 28 / 31 / 28 / 29 / 30
May
/1 / 2 /
MEDICATION: ______ROUTE: ______
DOSAGE (mg, ml, puffs): TIME: ______BEGINNING DATE: ENDING DATE:BEGINNING DATE: ENDING DATE:
Additional Instruction: ______
Note: Document time and initials when medication is given.
TEACHER:______GRADE:______
Student Name:______
5 / 6 / 7 / 8 / 9
12 / 13 / 14 / 15 / 16
19 / 20 / 21 / 22 / 23
NAME
*Please write additional comments below:Date / Medication / Count / Staff Signature(s) / Parent Signature
Shima 2013