altNiagara Catholic District School Board

    RECORD OF

    ADMINISTRATION OF MEDICATION
    Personal information on this form is being collected under the authority of the Education Act, in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and the Personal Health Information Protection Act (PHIPA). The purpose of collection is to identify protocols to follow in the event a student experiences symptoms pertaining to a prevalent medical condition. Questions about this collection should be directed to the Superintendent of Education, Student Support, Niagara Catholic District School Board, 427 Rice Road, Welland, ON L3C 7C1, (905) 735-0240.
     
    STUDENT PROFILE AND INFORMATION
     
    Student Name:  D.O.B.  


     
    School Name: OEN:  
       
    Name of medication Administered:
     
    Medication start date: Medication end date:   
          


           		 


     
    Date medication provided to Principal/Designate Amount of Medication provided to Principal/Designate Location of Medication stored within the school
    Amount of medication returned to Parent/Guardian at end of regimen
    Copy provided to Parent/Guardian at end of regimen ☐ YES ☐ NO
    Remaining medication returned to Parent/Guardian ☐ YES ☐ NO
     

     

         		      
    Parent/Guardian Name (Print) Signature  Date  
           
           
           
    Principal/Designate (Print) Signature  Date  


     

     



     
    DATE TIME DOSAGE ADMINISTERED STAFF SIGNATURE
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        


     

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    NOTE: PLEASE RETAIN A COPY FOR THE DURATION OF THE STUDENT’S ATTENDANCE AT THE SCHOOL