ADMINISTERING MEDICATION     Policy Code:   6125-E3

Medication Administration Incident Report

Name of School ____________________________________________________________

Name of Student ___________________________________________________________

D.O.B. _____________________ Date ___________________ Time __________________

Date and Time of Error _______________________________________________________

Name of Person Administering Medication ________________________________________

Describe Error and Circumstances Leading to Error:

____________________________________________________________________________

____________________________________________________________________________

Describe Action Taken:

____________________________________________________________________________

____________________________________________________________________________

Persons Notified of Error:

Supervisor _____________________________________________________________________

Principal ______________________________________________________________________

Parent ________________________________________________________________________

Physician (if applicable) ___________________________________________________________

Other _________________________________________________________________________

Signature (person completing incident report)

______________________________________________________________________________

Follow-up Information if Applicable: __________________________________________________

______________________________________________________________________________