NEPN/NSBA Code: JLCD-E4

INCIDENT REPORT – MEDICATION ADMINISTRATION

Name of School:

Name of Student:

Birth Date: Date: Time:

Date and time of error:

Name of person administering medication:

Name of medication and dosage prescribed: 

Describe circumstances leading to error:

Describe action taken:

Persons notified of error:

Building Administrator:

Parent:

Physician (if applicable):

Other:

Signature (person completing incident report):

Follow-up information if applicable:

5/06

5/2011

9/2012