ADMINISTERING MEDICATION Policy Code: 6125-E3Medication Administration Incident Report |
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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: __________________________________________________ ______________________________________________________________________________ |